Does a burr‑hole craniotomy result in a permanent postoperative indentation in the skull?

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Last updated: May 16, 2026 • View editorial policy

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Does Burr Hole Surgery Leave a Permanent Skull Indentation?

Yes, burr holes from craniotomy frequently result in visible and palpable skull indentations if left unreconstructed, with studies showing up to 60% of patients experiencing noticeable cranial vault contour irregularities at one year when only autologous bone dust is used for filling.

Understanding the Problem

Burr holes are circular openings drilled into the skull during craniotomy procedures or for drainage of conditions like chronic subdural hematomas. When these defects are not properly reconstructed, the overlying scalp can sink into the void, creating a cosmetically undesirable depression that patients can both see and feel 1, 2.

What Happens Without Reconstruction

The natural history of unreconstructed burr holes is problematic:

  • Bone reabsorption: When burr holes are filled with autologous bone dust (bone fragments from the drilling process), partial or complete reabsorption occurs in most cases by 12 months 1
  • Visible deformity: 60% of patients develop visible and palpable cranial vault contour irregularities when only bone dust is used 1
  • Scalp depression: The skin depletes into the unreconstructed holes, creating noticeable cosmetic deformity 2, 3

Reconstruction Options and Outcomes

Modern surgical practice emphasizes burr hole reconstruction to prevent these indentations:

Hydroxyapatite Plugs (Best Option)

  • Cylindric plugs made of porous hydroxyapatite provide superior long-term results
  • Show better esthetic and biomechanical outcomes compared to autologous bone dust at 12 months
  • Maintain thickness and prevent contour irregularities
  • Higher patient satisfaction without additional complications 1

Autologous Bone Grafts

  • Button-shaped grafts harvested from the inner table of the craniotomy flap can be used
  • Specifically designed to prevent postoperative cosmetic deformity 2
  • Less reliable than synthetic materials due to reabsorption risk

Specialized Burr Hole Covers

  • Commercially available devices designed to fill bone defects while allowing passage of catheters (for shunts or drains)
  • Shaped to alleviate deformity by filling the defect 3

Clinical Implications

The key distinction is whether reconstruction is performed:

  • With proper reconstruction: Minimal to no visible indentation, excellent cosmetic results 1, 4
  • Without reconstruction or with inadequate filling: Permanent visible and palpable depression in the majority of cases 1, 2

Special Considerations

  • Pediatric patients: Particularly vulnerable to enlarging defects, with rare cases of "growing burr holes" where the defect actually expands over time, especially in infants 5
  • Temporal region: Burr holes in the frontotemporal area are particularly prone to visible deformity due to thin soft tissue coverage 4
  • Long-term stability: Synthetic materials maintain better structural integrity than autologous bone over time 1

Bottom Line

Burr holes will leave permanent indentations if not properly reconstructed, but modern reconstruction techniques using hydroxyapatite plugs or specialized covers effectively prevent this cosmetic complication. The decision to reconstruct should be made at the time of initial surgery, as secondary reconstruction is more complex. Surgeons should routinely plan for burr hole reconstruction to optimize both functional and cosmetic outcomes 1, 2.

References

5
Research

Growing burr hole: enlarging pseudomeningocele at the site of a craniostomy.

Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery, 2004

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