Your Questions
Your Questions
Q: Dr. Eppley, I have contacted you in the past about questions I had regarding indentations I have on my skull, and about fixing them with a cranioplasty. You responded by telling me that I would require an open approach cranioplasty and the incision would be bilateral from ear to ear. Along with having a large indentations on my skull, I also am going bald. I am interested in getting a cranioplasty done by you and also am planning on getting a FUE hair restoration at some point.
My questions are:
1. If I was to get a FUE hair transplant/restoration would it be better to do it before or after the cranioplasty?
2. Would it make sense to do it after, so it mite be able to help cover the scar? or does it even matter?
3. Also can you diagnose what the name of the medical term/condition is that I have wrong with my skull by looking at the attached pictures I have here?
A: In answer to your questions, you would always want to do hair tranplantation AFTER a cranioplasty. This is because it would also give one the opportunity to place hair grafts along the scar should that be necessary. While this could always be done after, you would like to have that option during the initial FUE procedure. Usually that is not necessary but it is a theoretical option that you want to keep available given that bothi of these procedures are elective and can be done anytime in any order.
I believe what you have is a very incomplete form (microform expression) of bicoronal craniosynostosis. This is because you have deep indentations (like a constricting band) right along the exact location of the underlying original coronal suture locations.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have been bullied for a number of years over the shape of my skull and I am looking to do something about it as it’s ruining my life. The width is an abnormal shape and above the ears it sticks out quite a bit. I have read some of the questions on the website and seen Doctor Eppley’s answers which seem like it would be something that can assist me. Am I right in saying Doctor Eppley is the only person in the world who performs skull reduction surgery? I have spoken briefly with someone over email where I live but I am not sure the procedure they suggested is what I am looking for. I need to find the right procedure as I feel it is a necessity to have it done to be able to enjoy my life at all. I’m so depressed about it and I’m really searching for someone to help me before I get myself in to a bigger hole with the depression.
I have attached a picture. Are you able to say whether I can be helped or not please?
How long would I need to be in hospital for and when could I travel back home?
I’m worried about the strength of my skull after the surgery, I will be able to live a normal life afterwards won’t I, like play football etc??
I really appreciate your help and you taking the time to read this I understand you are very busy. Another question is that my ears are quite pointy/large and if I was to undertake this surgery I’m worried they will stick out even more, can anything be done with them so this doesn’t happen and they look a bit more normal?
I’m so sorry for so many questions. Whereabouts on my head would the incisions be? Would they be behind the ears and would they be quite deep scars?
I had thought about hair transplants at some point in the future because my hair seems to be disappearing rather quickly but I do prefer the shaved look if I’m honest. Do you think this would be a major problem?
I have to admit it has put a smile on my face knowing that you can possibly help. From the picture do you think the 5mm-7mm you mention in your questions section on the website will be enough to make my head look more normal in terms of shape?
Thank you so much for getting back to me.
A: Thank you for your inquiry and sending your pictures. From what I can see in this one picture (which is the most helpful view), there is temporal skull/muscle protrusion as well as ears that stick out a bit. This could be improved by a combination temporal muscle/bone reduction cranioplasty combined with a setback otoplasty.
This is a procedure that is done as an outpatient and one could return home in 48 hours. There would be no worries about the strength of your skull and you would not have any restrictions after surgery.
The most relevant issue is that an incision is needed on both sides to do the surgery and this is always a concern when it is a male who shaves his head or a has a close cropped hairstyle. We just have to be careful to not ‘trade-off one problem for another’.
To be certain we are looking at the same thing, I have done some before and after imaging to see if the changes that are possible is in line with what your objectives are. This is probably what a 5 to 7mm reduction can achieve.
The incisions would be vertical in the hairline just behind the ears and extending upward about 6 to 7 cms. They are not deep or indented scars but rather just fine lines.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have a pituitary tumor that made my skull grow very big. The pituitary tumor has been removed now and I am cured and cleared by my doctors. But the size of my skull is too big and very bothersome to me. It is very negatively impacting my self-image. My skull is too high up top and slopes down in the back. The temporal areas also stick out too far. How much skull reduction can be done to help me?
A: What I can tell you, with a lot of skull surgery experience, is that you can’t go deeper than the outer cranial table which often is anywhere from 5 to 7mms thick. Yours may or may not be thicker than that is some areas. At that point you enter the diploic space where a lot of bleeding occurs and the inner cranial table is not much further away. That is the limit of safety for any skull reduction procedure.
While 7mms may not sound like a lot of reduction, when done in a lot of areas of the skull, the external or visible appearance can be a lot more significant than the number sounds. It is common that patients think they need a lot more skull thickness reduction than they really do. I didn’t say that such a skull reduction result would be perfect or ever as much as some patients want. But is usually enough that patients feel it made a real difference.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in eyelid surgery (I'm Asian), nose surgery, jaw surgery and I have a small skull. I want some plate inserted to make my head fuller as I cannot tie back my hair without looking awful with small skull and square jaw. I need help as my self-esteem is very low and just can't accept my aging.When I was younger, I had a long face. Now that I am 43 years old my jaw got wider. I am short and this just makes me look uglier. My skull is small and flat on top for my face. I am okay with the back of my head. I want a fuller top without teasing up my hair to make my face proportional. I would like to be able to tie my hair back and tight without my face looking big and wide. I would like a deeper set of eyes and nicer nose too. I have expression lines across my nose. I wake up early for work and the fleshy eyelids means a lot of space for water retention. I have attached pictures for your review and thoughts.
A: Thank you for sending all of your pictures. Let me start by reviewing your requests based on the pictures that I see.
1) Eyelids – I see that you do have a high eyelid crease that is now overhanging with skin. I suspect given your ethnicity that you have always had a slight overhang with a crease but the skin is now overhanging more. Removal of the overhanging skin would be indicated which could be done to leave a little residual overhang or have no overhang at all, whichever is your preferred aesthetic result.
2) Nose – With your nose shape and ethnicity, the typical aesthetic goals would be a higher bridge and a narrower and more projecting nasal tip with possible nostril narrowing. Computer imaging will be needed to be certain of your exact aesthetic goals.
3) Skull – Based on your description, you desire a higher cranial height at the top located more to the back of the head. (vertex) This could be built up using a PMMA material with an increased height of approximately 10 to 15 mms using my standard skull reshaping techniques.
4) Jaw – Your wider lower jaw is as common ethnic feature that could be improved by either muscle reduction by Botox injections or jaw angle width reduction by lateral ostectomies. Given that these are rather different treatment approaches (noon-surgical vs surgical), it would be very important to have a precise understanding of your exact goals and their importance in this facial area.
What I would like you to do is to review these points, give me your thoughts on each and establish a list of the most important to least important changes on this list.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My head is very flat in the back (there is even a huge indent) which I believe has caused my head to grow wider from side to side than from back to front. My forehead is an odd shape and the top of my head is flat. Overall, I want to achieve a more oval shape to my head- less wide with a little more height to the top.
A: Thank you for sending your pictures. Based on the way you wear your hair in the back, I am assuming it is in a bun to mask the flatness. Generally with the back of the head is flat, the skull growth compensates by make it wider, so this is very common. With a wider skull, its height does need to be as high. So your overall skull shape fits for how it has developed. When changing a skull shape, the 'easiest' thing to do is to add volume. Volumetric skull additions can be more substantial (10 to 15mms) than skull reductions which are usually limited to around 5mms due to the thickness of the skull bone. Therefore the forehead and back of the head can be augmented with some minor reduction in the posterior skull width. This would definitely achieve a more oval shape to your head. When doing both the front and back of the head for skull reshaping, a bicoronal incision is needed to perform the surgery for adequate exposure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a pointy ridge of bone running down the center on the top of my head. Therefore when you look at me face on instead of the normal curve or round shape it looks more of a point. As I have to keep my hair short this makes my head look very odd. I didn’t think anything could be done until I just saw your before and after photos which has given me a little bit of hope. I hope you can help and look forward to your reply.
A: It sounds like you have a very classic sagittal ridge from front to back, a microform of sagittal craniosynotosis if you will. The midline ridge represents either an isolated thickening of the original sagittal suture or a midline ridge combined with some narrowing in the parasagittal out towards the temporal line. In most cases, it is the combination of the two that creates the look. Improvement in shape can be done by skull reshaping consisting of either sagittal ridge reduction alone or combined with a some build-up to the sides to make for a less high and more rounded skull shape. Very visible improvement in your skull shape is possible…provided you can accept a scalp scar to do it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is it possible for you to reshape my skull with an implant or permanent injectable filler? My head is flat at the crown and from most angles looks like I'm missing a part of my head. Instead of the typical incline from the brow to crown, mine does the opposite. It serves to elongate my lower face, throwing my facial proportions off balance. And as my hair is quite fine and rather volume-less, the way my hair frames my face, particularly when it's loose, is most unflattering.This is by far my main body issue concern and upsets me constantly. I can't seem to get past the frustration and I know it's in part because I can't hide this inside baggy clothes or some constant disguise. If I could ignore it, I'm sure I could forget it. But I can't ignore it when I have to look in the mirror each morning and do my hair. And then go out into the world feeling horrid. Here are some pics of imaged results that are my ideal. Would this be possible to achieve?
A: What your concerns are and are demonstrating is occipital augmentation and is the most common location for skull augmentation. Flatness at the back of the head is the number one cosmetic skull concern that I see and treat. The important question for every patient is how much skull augmentation can be achieved and is what is possible worth it for the surgical effort for the patient? What you are showing as your ideal result with computer imaging is exactly how I would have imaged it based on what I know is possible based on my own experience with this form of skull reshaping. That is a very realistic and expected result based on how much the scalp can expand to accommodate the expanded underlying bony contour.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to know if it is possible to reshape the back of head, specifically to build it up somewhat. I have attached pictures of what I want it to look like and want to know if this possible. The back of my head is too flat and looks weird and has always bothered me since I was a child. I live in Saudi Arabia and have seen 3 craniomaxillofacial surgeons in Europe, all of whom have told me they can't perceive what I take to be a problem and have suggested I suffer from body dysmorphia. It's been a frustrating experience. I will be visiting family in the US at the end of next year. If you tell me augmentation is possible, I would be very pleased to arrange a phone consultation with you and see you next year for surgery.
A: Your pictures show a very reasonable outcome from an occipital cranioplasty procedure. In my experience this is the most common area for a cosmetic cranioplasty augmentation. What you seek is neither unreasonable or unrealistic. What you have to understand is that this type of cosmetic skull reshaping is ‘new’, not the techniquies to do it but the concept that it is done for a cosmetic head shape concern. Thus you will find unfamiliarity, and perhaps even unacceptance, amongst most surgeons for this type of procedure. This implies that it is neither unsafe or not able to be done, just an unfamiliarity and lack of understanding that people can be bothered by the shape of their head just as much as they may be about the shape of their nose or their breasts. I suspect one day we will look back on cosmetic skull reshaping very much like people looked at the concept of breast implant augmentation in 1965.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I dont seem to fit the mold as far as the skull reshaping surgeries you have performed but I feel my head is so small. I am a male with a regular bodybuild and a small head. I have been made fun of my entire life. People can be so cruel they automatically make judgments from how I look in the oustide and don’t seem to care about the person inside. I hardly ever want to go outside anymore. I would love to know if there is any hope for me as far as my head size is concerned. I have to tell you my face is completely normal looking only if the top of my head was elongated about half an inch it would make a world of difference. I know if the shape of my skull could be changed my life would get a million times better. I have a few pictures so you can see what I mean.
A: Thank you for sending your pictures and expressing your concerns. Your skull shape concerns as I see them are not uncommon and I have recontoured such skull shapes before. I believe what you are seeing as a small head is a parasagittal front to back deficiency which likely represents a microform of sagittal craniosynostosis. This means that the skull bone has a contour flattening as it tails away from the midline sagittal ridge on both sides. This creates a bit of a peaked skull that is somewhat riangular in shape, making the skull look small and to not have a more rounded shape in the front view. I have seen this numerous times and it can be improved by an onlay cranioplasty that builds up the sides to raise it more to the level of the midline ridge height. I have attached a prediction image of what that result may look like.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I suffer from a congenital malformation of the face and skull. The shape of my face and my head is too skinny and started with me this problem since I was 15 years old. I am now age 29 years old and I want a solution to my problem. But before that I want to know the answers to the following questions:
1. Is it possible to find a surgical solution to my problem?
2. In the case of the possibility of surgery, you could be a final solution?
3. Can surgery be done through the addition of natural bones?
4. How serious is the surgery and what is the success rate?
5. How long will I need to heal, and to engage in normal life?
6. What will be the cost of surgery?
A: I would be happy to answer all of your questions but I will first need to see some pictures of your head for any assessment. It would be impossible to give an opinion without first seeing what the exact problem is. But what I can tell you without even seeing your skull problem is any correction can not be done by using bone grafts or natural bone. They will simple melt away and be absorbed. Skull surgery requires an incision across the top of the head so this is a trade-off you must be willing to accept. Most patients have full recovery after skull reshaping in just a few weeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wrote you before to inquire about a Skull reshaping using implants. I saw the archive “Cranioplasty Category” in your web site which shows the case were a 42 year old male was operate, and an implant was inserted in the back of his skull (occipital) in order to lengthen and correct a deformity, in this case a flat spot area. I must to say that it is a great job.
I have a similar problem, although it is not exactly like the example posted, in my case the flat spot is less notorious, but the overall profile of my skull is short. Moreover the rear of my skull is slightly above the level of the forehead. I think its because of some postural plagiocephaly caused when I was a baby.
I have some questions I want to ask you.
1) How much my scalp could be elongated in the back of my skull and the final appearance would look natural?
2) Would there be a very visible scar ?
3) Would I have to shave my head for the operation?
4) There is a risk that no hair grows up in the area of the implant ? cause i´m not bald
5) How long would I be hospitalized before and after the process?
I want to have the shape of the occipital area more pronounced. in order to have a more symmetrical shape of my skull. I know it´s difficult to answer my questions without seeing any images, So I could send you pictures of my two profiles to have a better idea.
A: In answer to your questions:
- A s a general rule, the skull can be expanded 10 to 15mm across the back without making scalp closure to tight or precarious for good wound healing.
- All forms of craniplasty require access through an incision. It heals as a fine line but there is a scar nonetheless. That needs to be taken into account when considering a cosmetic skull procedure.
- We do not shave any hair for cranioplasties. It is easier for the surgery if a patient did shave their head but we do not do it if the patient does not want to.
- The only risk of any hair loss is at the scar, not in the raised scalp flaps.
- This is usually done as an outpatient procedure in a surgery center, not a hospital.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What I am wanting to do is just reduce the high ridge on my head. That’s the only problem I have. My head seems as it has a bump right on top. I have attached three pictures to show you what I mean. it is pretty obvious.
A: What you have is a common condition that I see in aesthetic skull deformities, the prominent sagittal or midline ridge running from the front to the back. This gives the head a high arching or a triangular shape. What is important to realize about this skull deformity is that it is more than just a prominent midline ridge, the sides of the skull next to it are also too low. It is the combination of the two that makes it look that way. Thus to do its correction and achieve a rounder skull shape, both problems must be simultaneously addressed. It is more than just burring down the midline ridge as there is a limit as to how much that can be done. (usually 5 to 7mms) The sides along the ridge out to the temporal line must be built up as well with cranioplasty material. When done together the desired look is obtained as I have illustrated in the attached computer imaging prediction.
While this skull reshaping can certainly be done and is not difficult to go through, the key decision as to whether this is right for you is whether the incision and the resultant scar to do it is an acceptable trade-off. An incision would be needed across the top of the head with a resultant fine line scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a nephew with occipital plagiocephalhy. He’s 2 years old and we’ve been told there’s nothing else to do from a medical point of view. I’d like to know if there’s anything else that can be done, and when will it be a good time for him to go through any procedure if there’s still an option. We’d also like to know if it would better to wait, or to act now if there was something that could be done. Thanks.
A: At two years of age, a flat spot on the back of the head (occipital plagiocephaly) is not worthy of major skull surgery. (taking the bone off and reshaping it) This is what is meant by ‘nothing to do’. This does not mean there is actually nothing to do because there is, just not that particular surgery. Building up the flat area on the back of the head (skull augmentation) would be the appropriate surgery. This can even be done through a very small incision using an injectable bone cement technique. (injectable cranioplasty)
The question is not whether it can be done but when it should be done, if at all. There are no concrete answers to these questions. Such surgery is simple and takes less than an hour to do. Whether the size of the flatness justifies surgical improvement is a personal question as well as the timing of it. It can be done at two years of age or age 60. Correcting the flatness of the back of the head is a cosmetic issue. Thus the procedure and its timing are an individual decision.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am Yoga Weight Loss System interested in skull reshaping. I am a 28 years old man and the point being that the width of the upper part of my head above the ears is big and rounded on both sides. Can it be reduced and flattened ?
A: The wide or more square head shape that you have is due to a pronounced temporal ridge which is where the top part of the skull joins/transitions to the skull bone at the side of the head. This actually a ridge or line that starts in the forehead and goes to the back of the head. While this is always a transition area like two walls coming together in a corner but is usually a gradual transition. Your temporal line is very acute almost being 90 degrees.
This area can be snoothed down and made to look less square or wide. But the important question is whether it is worth the scalp scar trade-off to do so for the skull reshaping benefit. To access the area an incision is needed across the top of the head so both sides can be treated. While the skull width can be reduced, I am not sure in your case that is a good tradeoff.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a large bump on my forehead that has bothered me all my life. I am a 25 year-old man and this kind of gives me a ‘horned’ appearance. What are my options for getting rid of it? I have attached some pictures from different angles and it becomes really prominent when I raise my eyebrows and put wrinkles on my forehead.
A: Thank you for sending all your photos. The involved forehead area is quote distinct and, interestingly, does not allow any wrinkles to form across it. I suspect that is from the effect of pressure where the overlying forehead tissues are being pushed out more. The cause of this forehead ‘bump’ most likely is just a thicker area of forehead bone but I would always confirm that with a simple lateral skull x-ray before operating on it for burring reduction. This bump is moderately large so the issue is one of surgical access. I would definitely not make a hairline (pretrichial incision) because your hairline, like most males, does not appear stable for the long-term. The endoscopic approach could work but that also placed a sagittal (vertical) incision behind the hairline, that once again, may not prove stable. I think the best and most direct approach would be to use a horizontal forehead wrinkle line. This would also provide access to get the greatest amount of assured bony reduction which is obviously the intent of the operation. This form of frontal skull reshaping is actually very simple with minimal recovery, it is just all about how to get in to do it and where to ideally place an incision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 26 years old and have a really flat area at the back of my head. I am very self-conscious about this since I was 18.I want to kill myself to get rid of this pain. You would be my last hope. Please let me know if there is any way that I can fix this for a cosmetic purpose. Can something be implanted at the back of my head? I have attached a picture with my hair wet so you can see what is bothering me.
A: Having a flat back of the head is an aesthetic issue, not a problem that causes pain. While skull expansion can be done, I would nto expect it to emotional pain about the deformity but not actual physical pain. The key about building up the back of the head (occipital cranioplasty) is knowing the exact location where you want the skull expanded and a realistic assessment of how much expansion can be achieved. The limiting factor in skull expansion is always how much stretching of the scalp skin can be done. To some degree that is partially controlled by how much of a scalp incision a patient is willing to allow to be done. I have done some initial estimation of a result (attached imaging) although I am not clear where you see the need for the exact location of the correction of the flat back of the head. This imaging is just an initiation for further discussion about what you want to achieve.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, . I am currently 24 years of age. For several years now, after maintaining a short haircut, I have received comments from several peers that the back of my head is flat and that the posterior is slightly raised. It has come to the point where I felt I needed to do something about it. After research, I came across the term ‘positional plagiocephaly’. Because of the raised posterior, I find it uncomfortable to wear bicycle helmets as it will press on the posterior of my head. Headphones generally do not fit upright unless I tilt them to the front or back. Psychologically, I have suffered to some extent as it is hard for me to maintain a long haircut in my country’s humid climate and I am conscious about the shape of my head and would not like it to bother me as I develop my career. I would like to consult if my condition looks serious enough to warrant surgery for cosmetic reasons. I would also like to ask whether the skull reshaping surgery would reduce the height of my skull to a fair degree, so that the top of it looks more rounded, less angular and protrusive or if I should consult a craniofacial specialist to perform a more invasive procedure. I understand that without an x-ray, it is difficult to determine how much bone can be shaved off.
A:Your concerns about the shape of your head are of the most common variety that I see. A flat back of the upper skull and an increased cranial height in front of it often go together. It most likely was from early positioning issues as an infant but that is irrelevant now. The important question now is can it be improved and by how much. First, forget about any major cranial surgery at this point in your life. (actually anytime after two years of age) The bone is too thick and the magnitude of the surgery too great to take it all off and reshape it. This type of surgery, while working well in infants, is not an adult possibility. This leaves the option of external skull reshaping through either bone reduction (high posterior) and occipital augmentation. (building out the back) Together this can make a major difference if the scalp incision/scar required to do it is acceptable. Ultimately you are correct in assuming that an x-ray would be needed to see how much bone can be removed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, The right side of my skull is caved in and bulging therefore causing an asymmetrical appearance on my facial profile. From my right temple area, the skull leans towards the right, almost appearing to sag to the right side of my head. I wish to straighten that side so that both sides of my skull are structured straight up and are symmetrical. The pictures limit how much you can actually see, I believe an x-ray would do justice to my explanation. The problem is it bulges outwards. Whether it is muscle atrophy or bone, the cause was due to the way I would lay down on my side at 12 years old. The palm of my right hand would be pressed into my skull pushing the temple muscles upwards or inwards causing the deformed bulge. I basically used to use my right hand as a pillow, so my whole right face was subjected to being pressed into causing the disfigurement. It wasn’t the best way for me to lay but it was the most comfortable at the time. I put a lot of strain on my neck area, as my head and palm pressed into each other. Months afterwards, I noticed pain in my neck. Whenever I moved my right arm in a punching motion, I would feel a shock of pain surge through my neck causing me to yell out in pain. Migraines followed for sometime then stopped. My jaw was affected as well since my palm would push into it while my head rested on it. I can see a noticeable difference when I look at the right side of my maxilla and the left, the right is pushed in, so the top right row of teeth slant inwards. In response, it changed the alignment of my whole top row teeth in that it slants to the right. This is something I can see when I open my mouth, and using my tongue can feel the change including when I bite down on things. Then there’s the problem with my right nostril. It feels like it’s always stocked up in that whenever I sleep it tightens up so that I barely breath out of that side of my nostril. Also, whenever I’m in a warm environment, it closes and I’m forced to breath out of one nostril. I believe I damaged that area as well by applying pressure and somehow pressing inwards into the right side of my maxilla/nostril. It’s not congestion. So, here I hope is a general outlay of my problem and the problems along side it. I honestly believe an x-ray is much needed because a visual will better explain what words fail to. I can feel it and I’ve lived with the changes and a thorough scan of my head and neck will show you what I’m talking about.
A: You are correct in that the pictures don’t do justice to the skull/facial problems as you have described it. It would be highly unusual to reshape bone by any form of external pressure beyond the first few years of life but it is possible. That issue aside, I would agree that the best way to determine of your skull and facial issues are from bone or soft tissue deformity is to get an x-ray study. I can make those orders to any facility in your geographic location. The question is what type of x-rays would be best. The best type of x-ray to get is a 3-D CT scan of your craniofacial skeleton. That would provide an absolutely clear view of your skull and facial shape. In an ideal world, we would even get a model made from these x-rays which could even be used in treatment planning/designing the surgery. But from a cost standpoint, the bare minimum x-ray study you should get is a plain skull and facial series.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hope you doing great and you might recall our discussion regarding my cranioplasty last year (I have attached the mail and picture for you to recall). As you mentioned, I have flattening as well as surface is NOT even on back of skull, and I have hair loss as well. Would you recommend that I have hair surgery (FUE or FUT) method first and then go for surgery with you or surgery with you first and then hair transplant? Your advice will help me plan my surgery.
A: It is always best to have the skull augmentation first and then the hair transplant. Much like building a house, you should put the frame up before you can build the roof. Since the cranioplasty must now be done through an open approach (the injectable material is no longer available), the hair transplants can be used to help further camouflage the scalp scar if necessary.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have few questions about cranioplasty for my infant son.
1) I’ve read when it comes to cranioplasty, if done correctly and of course by the right surgeon, the scar would be generally “fine” not thick and the hair would eventually regrow on the scar after healthy healing, any truth to this theory?
2) If my recollection serves me correctly, I read when you inserted Kryptonite it was basically sort of like rolling the dice for the most part, because you didn’t EXACTLY know how it was going to turn out. It was basically a wait and see approach. Is it like this with the approach of inserting material in the skull? Or you pretty much have a good general idea by measuring and/or imaging of what it’s possibly going to look like before the surgery?
3) Since my son needs augmenting on the top of his head (right side) to correct/improve the head height differential, and also needs the reconstructing of his parietal bone, can this be done with one incision? Or you need 2 incisions?
4) For cranioplasty the scar will be approx. 4 inches correct (give or take)?
A: You have wisely and correctly interpreted what you have read. All four assumptions are correct.
1) Scalp scars in infants tend to be very fine. I would not always assume that hair will growth through the scar however.
2) Open cranioplasties do not generally have the contour/smoothness issues that are associated with an injectable approach because you can see what you are doing.
3) Only one incision would be needed.
4) The scalp scars are generally not longer than 8 to 10 cms.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a severe flat spot on the back of my head. I am 58 years old and there is not one single day goes by that I don’t despair due to this problem. I would be willing to be subject of a videoed production of the procedure to demonstrate the effectiveness and results of cranial reconstruction for those who may be considering such a procedure. I know there are alot of us out there and like myself, prefer to avoid the subject if possible, which is probably why the problem is addressed so seldomly. I have never reached out to a professional such as yourself because for most all of my life I have felt there was no hope for resolution to my problem, until now. I would be willing to send pictures if requested and any type of communication with you is possible at any time.
A: Your concern proves that it is never too late to care about a long-standing physical concern. Even at your age, it is perfectly safe and possible to have an occipital cranioplasty performed. There is nothing unique about your age that would prevent this extracranial augmentation being done very successfully. Skull augmentation, at any location from the forehead to the back of the head, is the simple addition of a material on top of the bone. It is almost more of a scalp surgery (incision and scalp flaps) than it is bone surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping for a prominent ridge down the center of my head. But I am concerned about the scar that is needed for the surgery. What are your thoughts on the scar and what can be done to make it heal the best?
A: The scalp scar in men for any type of skull or forehead surgery is always an issue to ponder very carefully. Whether it is worth it or not depends on a variety of factors including the magnitude of the deformity and one’s concern/focus on it, hair follicle density and hair style and the location of the scar on one’s scalp. I have done numerous skull reshaping procedures on men who are bald or shave their heads and the scar for them has been worth the trade-off. But I am certain that it was an acceptable aetsthetic trade-off because this very issue was discussed at great length beforehand and they have had plenty of time to make the proper determination for themselves about the scar trade-off. Scalp scars generally heal very well and how well they heal is largely determined by how the incision was made and how carefully it is closed with respect to preserving hair follicles.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a question about the skull contouring procedures that you do. My question is that can a small strip of bone be burred down from the top of my head which is pointed and thick, back down do the forehead? I’ve seen a video on Youtube where they do this for metopic synostosis.
A: What you are referring to is the reduction of a midline or sagittal ridge of bone, which represents the original fusion of the sagittal suture between the front (forehead) and back (occipital) fontanelles. In some people this line of sutural fusion can get quite thick and becomes a raised ridge of bone that can be quote prominent. This midline ridge of bone can be burred down (reduction cranioplasty) so that it is more level with the surrounding bone. How much it can be reduced depends on how thick the skull is along the ridge.Usually the ridge is thicker than the surrounding bone so that is not a problem. But it is a good idea to check its thickness first with an x-ray before actually having the procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 30 year old male with a odd shape head that hunts me still now. I keep a lot of hair on my head to give my head a fuller look. I also constantly cover my head with a bandanna, sleep with it on my head, never remove it. My head sweats, get dried and builds up a bad case of dander because I hate my head shape and smallness…. I need help with this problem and people is driving me crazy, I haven’t been outside normally for 13 years, only go out when I have no choice. It is all my mother fault, she shaped my head by pressing on it when I was a child because she believed wide flat foreheads are a great look for men but she done it all wrong, I am flat front and back, my skull is small as well…. please help me!
A: Your description of your unhappy head shape sounds like fronto-occipital flatness. This could be improved by augmentation of your forehead and the back of your head by an onlay cranioplasty. Whether both areas should be done or just the front or the back would depend on the area of the greatest aesthetic concern. How much augmentation can be done depends on what your scalp will permit by stretching. By using a coronal scalp incision between the two areas, good scalp expansion can be obtained and the closure of the incision is well away from the material location which is always a bonus.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions about building out a flat spot on my skull. I have attached some pictures for your evaluation. My questions are:
1) Since the Kryptonite material is no more available there is only the PMMA,Hydroxyalite(HA) and custom silicone implant available. If I understand well all these materials are requiring an open approach under general anesthesia for two hours
and they all leave a scar between 8-10cm when they are introduced under the scalp. Will the scar be visible if i keep my hair a little longer then short?
2) Other than a scar ,minor contour issues remain as the only risk. If these contour issues ever occur later after surgery, what have to be done and how?
3) Hydroxyapatite material bonds to the bone with no risk of osteolysis. Does it make then (HA) safer than PMMA in that matter?
4)What is the biggest disadvantage in using hydroxyapatite material?
5) The safety is my biggest concern long after the surgery, which of these materials are best proven over the years?
6) I would be traveling from abroad. How long do I have to stay in the U.S. and do I need some special medical insurance in case something goes wrong during the surgery.
A: Based on your photos, what I see you are demonstrating is a severe flatness to the back of the head, lack of occipital projection. In answer to your questions:
1) The posterior scalp scar is about 8 to 10 cms that with hair will remain hidden. There are numerous bald.shaved patients who have the procedure as well but I think it is a good idea to be well aware of the scar potential.
2) If any contour issue arises, such as an edge than one can feel or some asymmetry, it can be easily adjusted/fixed through the same scar approach. I go to great lengths to avoid that happening for the obvious reason…no patient wants to go back to surgery. But despite my best efforts, surgery is not always perfect.
3) HA does have a direct bone to bone so, in theory, it is a more biocompatible material. I wouldn’t use the word safer as both materials have been used successfully for decades. But if I was a young person and had a choice between the two materials (cost is the big issue) then I would go with HA>
4) Cost is the only disadvantage to the HA material. By volume alone, it takes twice as much HSA to get the same volume effect as PMMA>
5) PMMA has been used as a cranioplasty material for over 40 years. HA has been used for over 25 years.
6) Almost all cranioplasty patients return home within 48 hours after surgery. No special medical insurance is needed as nothing is going to go wrong that would warrant any catastrophic medical care. This is the simple addition of a material on the outside of the skull bones, it is very safe. The risks of this surgery are aesthetic concerns not significant medical complications.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, regarding the skull augmentation will the bone cement be set beneath the periosteum. Could that involve any risk of “osteolysis”? Could the bone cement be put on the periosteum instead? Thanks!
A: Your question is an interesting one and is only relevant based on the type of cranioplasty material that may be used. When using any of the hydroxyapatite (HA) formulations, you definitely want to be under the periosteum for two good reasons. First, the material does bond directly to bone with no risk of osteolysis and you want to take advantage of this biologic benefit. Secondly, if HA materials do not bond to the bone they will ultimately be unstable and may likely shift position afterwards and develop fractures or fragmentation of the materials at their feather edges. When it comes to poly methylmethacrylate (PMMA) cranioplasty material, this can be placed on top of the periosteum and will set up and will likely not shift or fragment afterwards particularly if microscrew anchorage is used. PMMA materials, unlike HA, do have a known and low risk of settling into the bone a little bit and are what you refer to as ‘osteolysis’. But this is not a particularly progressive process and is self-limiting. Conversely, I have greater concerns for its effects on the overlying scalp and tissue thinning. Therefore I think it more important to provide as much barrier between the material and the overlying scalp tissues as possible and would recommend staying beneath the periosteum for this important long-term reason.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I googled “skull reduction” and found out that you are the only one in the world who does skull reduction. I see you need a bicoronal incision for this, which is not a problem. I have a big head and can’t wear hats and I am always teased. I read that reduction is achieved throught a rotatory instrument that shaves done the external layer. You said to think about an oreo cookie. When do you reduce the skull, do you only use this instrument or you do osteotomies as well? If you burr the bone doesn’t the skull become weaker and more susceptible to fractures or soft to the touch? Do you perform a lot of these procedures?
A: In answer to your questions:
1) Cosmetic skull reduction is done by burring down the bone,, not by osteotomies. Osteotomies are major cranial bone flaps are not indicated for cosmetic improvement.
2) The skull does not get appreciably weaker with outer cranial table reduction as there remains an inner diploic layer as well as an inner cortical bone layer as well to the skull.
3) Various forms of skull reduction/reshaping are done in my practice. Whether anyone is a reasonable candidate depends on many factors and I would have to seem some pictures of one’s head to determine if they are a reasonable candidate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a severe skull shape problem that has been with me all my life. My skull is weirdly shaped like an alien. I am tired of being made fun of because of my head shape. I have seen a few doctors by they all say that nothing can be done and I should just live with it. I know you are an expert in this area so I thought I would ask you as no one else seems able to help. Attached are some pictures from different angles.
A: Thank you for sending your pictures. The shape of your skull appears to be the result of a congenital sagittal craniosynostosis condition that has been undiagnosed and untreated. This explains the very long, higher and narrow head shape that you have. Unlike the surgery done as an infant for this condition (take the bone apart, some of it completely off and put it back reshaped), that approach can not be done as an adult. The best that can be done now is to reshape the skull somewhat from manipulations on the outside. This would entail some reduction of the prominent midline ridge and some reduction contouring of the forehead. The sides would then be built up to make it wider. This type of cranioplasty requires being done through an open scalp incision for access to all of the skull areas. This would provide some definite improvement although it can never be an ideal or perfectly normal shaped skull.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to have a normal shaped-head. I have neurosurgery two years ago and the bone flap had to be taken out and frozen due to brain swelling afterwards. It was put back in at a second operation but as it healed it became very uneven. I have dents and visible screwheads throughout my entire forehead. One of the screws also became loose and had to be removed later. Also my forehead is so narrow and looks like an alien. I just want to look close to what I used to before the accident, a more normal shape head with noindents and bumps sticking out. You can see in my forehead photos how unusual my forehead looks.
A: The re-implantation of skull bone flaps, while necessary, is often fraught with bony resorption and irregularities. In addition, the metal hardware used to place it often become visible or loose as you have experienced. The good news is that vast improvement can be obtained by an onlay cranioplasty. Using your original scalp incision, the bone can be re-exposed, all existing metal hardware removed and the entire forehead and skull area covered and built up in a smooth and symmetrical fashion using any of the several available cranioplasty materials. This is a highly successful procedure that is not associated with any of your prior problems with bone flap replacement surgery.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana