Your Questions

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, 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