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Dr. Barry Eppley

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Archive for the ‘cranioplasty’ Category

Case Study – Minimal Incision Bone Cement Occipital Cranioplasty

Sunday, November 22nd, 2015


Background: Skull deformities of the back of the head are very common. It is probably the one skull area that has the greatest incidence of shape distortions. This likely occurs because it is the most exposed skull area to deformational force both in utero and after birth due to fetal and neonatal positioning. Thus flat spots on the back of the head are common and occur in a wide variety of locations and extent.

Aesthetic reconstruction of the flat back of the head can be done by a variety of implant techniques. The most common skull reshaping technique today is the use of a custom occipital implant made from the patient’s 3D  CT scan. This works well for large flat spots on the back of the head (brachycephaly) as well as those that are associated with some significant asymmetry. (plagiocephaly)

While a custom implant would also work well for smaller flat spots, the cost and the time of manufacture for some patients may exclude this as a treatment option. The use of traditional cranioplasty bone cements, such as PMMA, provide an immediate and relatively low cost skull implant option that can be done immediately and with good long-term results. The key to its aesthetic use is a small incision and getting good shaping of the material as it cures.

Case Study: This 31 year male was bothered by a very discrete flat spot on the central area of the back of his head. It created a sharp step-off at the very end of the sagittal skull area, creating a 90 degree angle between the top of the head and that of the back of the head. Due to cost and being from out of the country, a custom implants was not an implant option.

Occipital  Cranioplasty intraoperative result Dr Barry Eppley IndianapolisMinimal Incision Occipital Cranioplasty incision Dr Barry Eppleyh IndianaspolisUnder general anesthesia in the beach chair position, a 5.5 cm horizontal scalp incision was made at the bottom end of the flat spot. Through this incision antibiotic impregnated PMMA cranioplasty bone cement was mixed and 40 grams of it as introduced under the widely raised subperiosteal scalp flap over the flat spot. The cement was shaped externally and allowed to set with a focus of smooth edges around the cement’s perimeter. A good intraoperative back of the head contour was obtained.

Minimal Incision Occipital Cranioplasty with PMMA result side view Dr Barry Eppley IndianapolisMinimal Incision Occipital Cranioplasty with PMMA result left side view Dr Barry Eppley IndianapolisAt one week after surgery both profile views of the back of his head showed good shape improvement.  It takes about three more weeks for all scalp swelling to completely resolve. He had simultaneous otoplasty procedures as well hence the bruising around his ears.

A minimal incision PMMA bone cement cranioplasty relies on shaping the material in a blind fashion once placed into the created pocket. There is no forgiveness for any edge transition or step off problems between the cement and the bone since is no way to access them for adjustment (burring reduction) through such a small incision. This is a learned cranioplasty techique that takes a lot of experience to do consistently well.


  1. Defects of the back of head (occiput) occur in a wide variety of shapes but a flat spot is often the predominant problem.
  2. The use of PMM bone cement can be used for selective flat spots on the back of the head.
  3. A small or minimal incision approach can be done for a PMMA bone cement occipital cranioplasty but placing and shaping the cement is a learned skill.

Dr. Barry Eppley

Indianapolis, Indiana

Skull Augmentation in Young Children with Plagiocephaly

Thursday, November 12th, 2015

plagioccephalyPlagiocephaly is a term used for a broad collection of congenital skull deformities that involve a general twisting or rotation of the skull base. This is most commonly seen as flattening on one side of the back of the head with compensatory changes anteriorly to the forehead and face. When diagnosed early skull molding therapies with helmets can be very effective in lessening the head shape deformity. But if not treated within the first year of life, the success of cranial molding therapy decreases significantly.

Unlike more severe skull deformities like craniosynostosis, plagicephaly is not generally viewed as severe enough in many cases to warrant major intracranial surgery through bone removal and reshaping. Flat areas on the back of the head are viewed as ‘cosmetic’ with no medical indication for surgical intervention…as viewed from the typical craniofacial surgical perspective. Certainly it is hard if not impossible to justify a major operation with a long scalp scar and need for blood trasnfusions to correct a mild to moderate occipital skull shape problem in a young child.

It is common in my practice to correct a wide variety of skull shape issues in adult with ‘aesthetic craniofacial’ techniques. This essentially means two fundamental approaches that differ from traditional craniofacial surgery methods…a very limited scalp scar and correction of the deficient skull with onlay bone cement methods. This requires experience in working with a variety of alloplastic cranioplasty materials and doing so with limited incisional access. This has proven to be a very effective approach with good skull contour improvements.

hydroxyapatite cement skull contouring dr barry eppley indianapolisThere is no reason that such a limited incisional skull contouring procedure can not be safely and effectively applied to young children with plagiocephaly skull concerns. The key component to this approach is the type of contouring material (bone cement) that is used. A bone cement material like hydroxypatite cement, while synthetic, has a highly osteoconductive surface and allows bone to bond directly to it. (does not develop a scar interface like a truly synthetic material would) While never being resorbed and replaced by actual bone, it is extremely well tolerated and will allow any remaining skull growth to be unimpeded. (At three to four years of age, the skull has undergone over 70% of eventual skull size anyway) Thus the skull contouring effect achieved will be maintained as the child continues to grow.

Having done a small series of hydroxyapatite cement skull augmentations in children (under age 5) for flat spots on the back of the head, it is an effective procedure with a very quick recovery. Most scalp incisions have been less than 5 to 6 cms in length. It is a challenge to work with bone cements through such a small opening but years of experience with the material have helped tremendously.  For the very motivated parent(s), treatment of mild to moderate plagiocephaly can be vey safely done at a young age.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Skull Implants for Head Widening

Tuesday, October 13th, 2015


Background: The shape of the head can be quite variable amongst different people. While often perceived as a smooth oblong shape, some people are not as blessed with such a smooth and symmetric skull. The skull can have a large number of asymmetries and deficiencies that may be of concern to the patient but unperceived by others due to coverage by hair.

One skull dimension is that of width. The width of the skull is composed of the temporal, parietal and upper forehead areas which is composed of a combination of bone and muscle. The width of the head can affect its appearance in short hair and can even affect how tight or loose hats and other head wear feel. While there is no exact number for ideal head circumference, the more practical issue is how it looks and feels.

Changing the width of the skull is often perceived as not being possible. But with today’s 3D implant design technology a wide variety of skull augmentation possibilities exist.

Head Widening Implants design Dr Barry Eppley IndianapolisHead Widening Implants design side view Dr Barry Eppley IndianapolisCase Study: This 65 year old male had been bothered his entire life by a head shape concern.  He had trouble wearing hats and he had a noticeable asymmetry of his forehead. Since his hairline had receded a bit the forehead asymmetry became more apparent. The sides of his head were too narrow at the junction of the sides and top of the skull along the temporal lines. This caused a backward slope to his forehead which was most severe on his left side. Using a 3D CT scan, bilateral custom skull implants were designed to add volume and correct the asymmetry. It was very important that the front edge of the skull implants had a very feather edge so there was not a visible implant transition.

Bilateral Head Widening Skull Implants intraop Dr Barry Eppley IndianapolisBilateral Head Widening Skull Implants screw fixation Dr Barry Eppley IndianapolisUnder general anesthesia he has his custom skull implants inserted through 5 cm long incision at their back end. The implants had perfusion holes placed in them and were inserted in a rolled fashion. Once inserted they were unrolled, positioned and secured with a single 1.5mm microscrew per side.

Widening of the upper sides of the head can be successfully done through the use of custom skull implants. The implants will sit partially on bone and partially on the temporalis muscle fascia. They must be designed to have very thin edges all the way around the implant. With thicknesses of even 7mm, a total upper head width change of 15mms can make a very noticeable change.


1) Narrow head widths can make wearing hats difficult and can cause forehead asymmetry.

2) Paired custom skull implants can add width at the upper temporal and sides of the top of the head.

3) Custom skull implants can be inserted through fairly small incisions at the back of the head.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Funnel Insertion Technique for Injectable Occipital Cranioplasty

Monday, July 13th, 2015


Background: Flat spots on the back of the head or one-sided occipital flatness is not rare. While the back of the head is typically round, it is prone to numerous indentations and irregularities from in utero and neonatal influences. Since the back of the head is exposed to greater eternal pressures than the rest of the head combined, occipital deformations such as flat spots are not uncommon.

Correction of occipital defects or indentations can be done by a variety of bone augmentation techniques. The key differences are in what material is used and how it us introduced. Having performed many skull augmentations over the years there is no question that the single best method is a custom skull implant placed through a low occipital incision. But there still is a role in the patient for other forms of skull augmentation, particularly in unilateral occipital plagiocephaly. (flatness on one side)

Case Study: This 42 year-old male had always been bothered by a flat area on the back of his head. This had been there since he was a child. His mother said it happened because he laid on that side of his head since he was born and always turned back to it. It bothered him to the point that he would always wear a hat to hide it.

Minimal Incision Occipital Cranioplasty Dr Barry Eppley IndianapolisFunnel Insertion Cranioplasty Dr Barry Eppley IndianapolisUnder general anesthesia in the prone position, a 4 cm horizontal incision was made near the area of occipital flatness. Wide subperiosteal dissection was done to develop a pocket into and around the area of skull flatness. Using a funnel insertion device, 60 grams of PMMA was introduced through the incision into the subperiosteal pocket. The incision was temporarily stapled closed and the material in its putty form was shaped externally until it set into a hardened state.  The incision was then unstapled and all edges checked for smoothness. Then the incision was closed with dissolveable sutures.

Funnerl Insertion Cranioplasty result back view Dr Barry Eppley IndianapolisFunnel Insertion Cranioplasty result oblique view Dr Barry Eppley IndianapolisHis results showed a much improved shape of the back of the head that was more symmetric. There is no truly injectable cranioplasty or skull augmentation method in the truest sense of the injectable concept. (through a small needle with no incision) But PMMA cranioplasty material can be ‘injected’ (introduced) through a small incision and shaped by external manual molding. The funnel device is exactly that used for the insertion of implants in breast augmentation. Identical to a confectioner’s funnel for icing, PMMA bone cement can be used to aid into scalp pockets developed by subperiosteal instrument manipulation.


1) Smaller back of the head corrections for flat spots can be done by a near injectable bone cement technique. (injectable occipital cranioplasty)

2) This type of injectable cranioplasty requires a small incision and the bone cement is inserted through a funnel apparatus. This should not be confuse with a purely injection technique like that used for facial soft tissue fillers.

3) An injectable occipital cranioplasty requires shaping of the material as it sets from the outside through scalp molding.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Perfusion Holes in Skull Implants

Sunday, March 15th, 2015

Aesthetic cranioplasty often involves the coverage of large skull areas with alloplastic material. Whether it be PMMA or hydroxyapatite cements or with today’s custom 3D generated silicone implants, a fairly large amount of material can serve as a solid interface between the overlying scalp and the underlying cranial bone. As the scalp has an excellent blood supply through major arterial pedicles, the placement of such skull implants do not pose any vascular compromise to the scalp tissues in general or to hair growth in particular.

But there are risks to consider in the use of larger skull implants such as scalp tissue adherence and the development of seromas (fluid collections) after surgery. It is easy to see how these might occur since the scalp normally sticks back down to bone and seals its lymphatic channels by such healing. Any implant material, however, creates a surrounding capsule to which the scalp sticks but the capsule itself does not adhere to the material as firmly as natural scalp tissue sticks to bone. The capsule itself can also be a source of chronic fluid egress particularly in secondary surgery where an established capsule exists.

Cranioplasty Pefusion Holes Dr Barry Eppley IndianapolisWhile the development of these skull implant issues are rare in my experience, there is a simple intraoperative manuever to help their prevention. The placement of many small holes through the material, known as perfusion holes, can help re-establish a fibrovascular connection between the scalp and the underlying skull bone. The more holes that are placed the more small connections that are made. In solid PMMA bone cement 2mm holes are made with a handpiece and burr. It is only necessary to go through the material and not into the bone. But there is no harm in doing so if the outer cortex of the bone is penetrated.

Skull Implant Perfusion Holes Dr Barry Eppley IndianapolisIn custom silicone skull implants these perfusion holes are made with a 2mm or 3mm skin punch. This is easy and quick to do. How many perfusion holes to make is not precisely known but more is probably better than less.

The placement of perfusion holes in aesthetic skull implants, in addition to recreating a vascular connection, also serves to have a quilting effect. With the tissue ingrowth through the holes, a small soft tissue ‘anchor’ is created. This in effect takes a large subcapsular space around the implant and turns it into many smaller compartments. This serves not only to anchor the overlying scalp to the implant but also can have a seroma prevention effect.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study – PMMA Cranioplasty for Moderate Flatness of the Back of the Head

Saturday, February 21st, 2015


Background: Excessive flatness of the back of the head can affect women and men equally. While shorter hairstyles reveal the shape of the back of the head most clearly, women with longer hair can be similarly affected and use various hairstyling methods to camouflage it.

PMMA Cranioplasty Material Dr Barry Eppley IndianapolisThere are various materials by which the back of the head can be built up. Each has their own distinct advantages and disadvantages. PMMA bone cement has been used for many decades for various forms of inlay and onlay cranioplasty. As an onlay, PMMA is most commonly thought of as a forehead augmentation material. But it can work just as well on the back of the skull as it does on its front side.

Case Study: This 35 year-old male had long been bothered by the flatness of the back of his head. It had been present since birth and he felt that the shape of the back of his head was unusual and out of proportion to the rest of his skull shape. Building up the back of his head would help give him a more normal shape.

PMMA Occipital Cranioplasty Dr Barry Eppley IndianapolisPMMA Bone Cement Occipital Augmentation results side view Dr Barry Eppley IndianapolisUnder general anesthesia, am 11 cm long incision was made across the top of his head near the back. The occipital skull was exposed and the flatness at its superior aspect evident. Three small 1.5mm screws were placed with their heads above the surface of the bone for cement anchorage. Using 60 grams of PMMA cement mixed with antibiotic powder, the putty was applies and shaped until set to give the back of his head a more rounded shape. The scalp incision was closed with resorbable sutures.

PMMA bone cement remains an historic and proven method of occipital augmentation for treatment of moderate degrees of back of the head flatness. Because the cement must be placed as an initial putty and then shaped after application, it requires an open approach with careful attention to its symmetry of shape and edge transitions. Because the cement is initially ‘soft’ it has a limited ability to create much scalp push. This limits the amount that can be placed to 60 to 90 grams through more limited scalp incisions and flap elevations.

Case Highlights:

1) Flatness of the back of the head can be corrected by a variety of onlay augmentation methods.

2) The use of PMMA bone cement is the most cost effective form of occipital cranioplasty.

3) PMMA cement is useful for small to moderate amounts of occipital augmentation requirements.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Case Study: HTR Occipital Implant for Flat Back of the Head

Sunday, January 11th, 2015


Background: The flat back of the head is one of the common aesthetic skull deformities. It usually originates from either a genetic predisposition or a deformational effect of in utero or post birth head positioning. (occipital plagiocephaly) The flatness can be on just one side or both. (bilateral) When it occurs bilaterally there are aesthetic issues of skull disproportion that often bothers the person enough that they may great efforts at camouflaged by various hairstyles and hat wear.

Cosmetic correction of the flat back of the head is done using a variety of onlay implant materials. The contour of the bone is expanded through subperiosteal augmentation whose amount is controlled by the ability of the overlying scalp to expand.Those materials that are applied and shaped intraoperatively are several types of bone cements. (PMMA and hydroxyapatite cement) Preformed custom occipital implant materials include silicone, Medpor, HTR and PEEK. Of these custom shaped materials, only silicone is soft and flexible while the other polymers are quite rigid.

HTR Cranial Implants Dr Barry Eppley IndianpolisHTR (Hard Tissue Replacement) is a well known cranioplasty material. It has been used as a custom made implant for cranial defects for over 25 years. It is a unique polymer material because it is both porous and hydrophilic. These material characteristics allow it to become well vascularized throughout its thickness after implantation. It has a very successful history of inlay reconstructive use for skull bone defects but has been very rarely used as an onlay material for aesthetic augmentation.

Case Study: This 38 year-old male had a very flat back of the head for which he had prior attempts at occipital augmentation. He had a prior occipital implant (material unknown) placed through a long coronal scalp incision which ultimately became infected and had to be removed. This left the back of his scalp scarred and more rigid than normal. He thoughtfully considered all the implant materials and chose HTR because of its potential to become vascularized throughout the material. A 3D CT scan was used to create an occipital implant design of 18mm thick at its central portion.

HTR Occipital Implant Scalp Flap Elevation Dr Barry Eppley IndianapolisIn the prone position under general anesthesia, his original high occipital scar was completely cut out down to the bone. An occipital scalp flap was developed down to below the nuchal ridge at the base of the occipital bone. While the scalp flap raised easily it was very thick and inflexible. Extensive cross cuts in a grid pattern were done through the scar to create a full occipital flap release to create enough tissue looseness to close over an implant augmentation.

HTR Occipital Implant positioned Dr Barry Eppley IndianapolisThe HTR occipital implant was soaked in antibiotic solution and placed in its proper position on the position. It was secured with small plates and screws in a triangular pattern. Because the edge of the HTR material can not be made paper thin, a layer of PMMA bone cement was used to create a smooth transition from the implant to the bone.

HTR Occipital Implant Augmentation result intraop top view Dr Barry Eppley IndianapolisHTR Occipital Implant Augmentation for Flat Back of the Head Dr Barry Eppley IndianapolisWith an 18mm expansion in a previously operated and scarred flap, even with using a full coronal incision, the wound closure was tight over the implant. Fortunately no wound separation developed when the staples were removed. He went on to heal uneventfully, has developed no infection or fluid collections and is satisfied with his results.

Rigid implant materials like HTR can be successfully used in aesthetic skull augmentations. But the material characteristics makes for the need to use a long scalp incision for placement and some experience on knowing how to properly secure it without fracture or palpable implant edges.

Case Highlights:

1) Occipital augmentation skull reshaping surgery can be done by custom implant materials like HTR which is also porous.

2) Because HTR is a hard inflexible material it must be placed through a full coronal scalp incision.

3) Fine edging of HTR as an onlay material may need to be supplemented with a bone cement material to create perfectly smooth edge transitions.

Dr. Barry Eppley

Indianapolis, Indiana

3D PEKK Implants For Complex Craniofacial Reconstructions

Sunday, August 31st, 2014


The concept of 3D printing of human replacement parts has been all over the medical and scientific news over the past few years. While each news release seems like it is revolutionary and new, most are the natural evolution of the refinement of 3D CT scanning and the ability to manufacture custom replacement parts from these images from various synthetic materials. This is of specific relevance to the skull and face where their complex anatomy make shaping natural tissues to fit difficult and often lacking inadequate donor volume to do so.

I have performed custom skull and facial reconstructions made of either HTR polymer or titanium for over twenty years…and custom silicone skull and facial implants for aesthetic enhancements over the past three years. As good as these synthetic reconstructions have been, there is always room for improvements and further technical advancements.

OsteoFab PEKK Skull Implants Dr Barry Eppley IndianapolisOne of these has been in the evolution of improved materials for custom implant fabrication with the use of the polymeric material PEEK. (polyetheretherketone)  This is a colorless organic thermoplastic polymer from the polyaryletherketone (PAEK) family. This material has excellent mechanical properties with a Young’s modulus of 3.6 GPa and a tensile strength of around 90 to 100 MPa. It is resistant to breakdown (melting) up to temperatures as high as over 340 degrees C (650 degrees F) In addition to resistance to thermal degradation, it is also highly resistant to breakdown by a wet environment or organic enzymes.

OsteoFab PEKK Facial Implants Dr Barry Eppley IndianapolisCustom implants made from PEKK were first FDA-approved in 2013 for cranial reconstructions and just recently approved in 2014 for facial reconstructive parts. (OsteoFab, Oxford Performance Materials) Through their processes it is possible to print patient-specific implants from either 3D CT or MRI scans. The implants are 3D printed and combined with laser sintering manufacturing technology and proprietary OXPEKK powder formulation to print skull and facial implants. These implants are biocompatible, mechanically similar to bone, radiolucent, and osteoconductive.

PEKK craniofacial implants offer several advantages over the traditional use of metal materials such as titanium or stainless steel. They have reduced weight, do not ever corrode, can be tailored to meet complex shapes with great precision and differing biomechanical loading properties. They also have a density and stiffness similar to bone and are radiolucent. (do not cause scan scatter) Some evidence also indicates that it has osteoconductive properties.

PEKK craniofacial implants is just one example in a long line of 3D printed biomedical advances. This technology and material allows complex craniofacial cases to be treated in a more precise manner that is ultimately more cost effective. While the actual implant(s) is not inexpensive, the savings in operative time and expense, need for donor site harvest and the high likelihood of subsequent revisional surgeries justifies the up front fabrication costs.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Skull Dimple Correction by Augmentation Cranioplasty

Monday, March 17th, 2014


Background: While the shape of the skull is typically smooth, it is not rare that one may have various small contour deformities. These could be raised or indented areas depending upon their location on the skull. Many of these skull shape issues are related to their initial formation through the cranial sutures and their fusion posts known as fontanelles.

Skull Fontanelles Dr Barry Eppley IndianapolisAt birth a baby has six distinct fontanelles. The larger anterior and the somewhat smaller posterior fontanelles in the midline are the most noticed due to their size. These well known soft spots are where the skull bones have not yet fused. They exist to allow the skull plates to move, permitting easier passage through the birth canal as the head is able to change shape. After birth, they allow the baby’s brain to grow since the skull is not a fused box of bone yet. The anterior fontanelle may remain open until about 18 months of age while the posterior fontanelle usually closes by 3 to 4 months of age.

But sometimes when the fontanelles fuse, they may not fill in completely with bone of normal thickness. There may no longer be an open area between the bone edges but a complete outer and inner cortex with a well formed diploic space may not fully form. This creates an indentation in the skull or a skull dimple which appears as a circular midline depression which feels like a small crater.

Skull Dimples Indianapolis Dr Barry EppleyCase Study: This 27 year-old male was bothered by a depressed area, about the size of his thumb, on the back of his head. The overlying skin was contracted inward and the whirl pattern of his hair was directly over it. The indentation was firm with no dural palpations and was located over the area of the original posterior fontanelle.

Skull Dimple before and intraop Dr Barry Eppley IndianapolisSkull Dimpleplasty Dr Barry Eppley IndianapolisUnder combined sedation and local anesthesia, a small curved incision was made behind the skull dimple. The firmly adherent soft tissues were elevated out of the bony indentation as well as around the rim of the bony defect. The defect was then filled to the level of the surrounding skull bone with an hydroxyapatite bone cement. The scalp was closed with small resorbable sutures. A compressive dressing was then applied.

There is always some small amount of scalp swelling afterwards and, occasionally, some fluid will accumulate over the augmented area. This always resolves in a few weeks as the fluid is absorbed and the final skull contour appreciated.

Skull dimple correction is the smallest form of an onlay cranioplasty. It is simple, effective and has no real recovery associated with it. Any form of bone cement will work to fill the defect. Whether it is an open or a more injectable approach, the technique chosen is the one that can create the smoothest skull contour.

Case Highlights:

1) It is not rare for the skull to have indentations or dimples, most commonly occurring at the location of a previous fontanelle.

2) Skull dimple augmentation or skull dimpleplasty is a limited skull procedure that fills in the bone defect by application of a bone cement material.

3) Skull dimple augmentation can be done through either a small open incisional approach or an even smaller incisional injection technique.

Dr. Barry Eppley

Indianapolis, Indiana

Minimal Incision Forehead Augmentation Cranioplasty

Monday, October 7th, 2013


Forehead augmentation is done for a variety of aesthetic reasons including increasing the convexity and projection of the forehead. A forehead that slopes back too severely or lacks brow bone projection can be built up by an onlay or augmentative cranioplasty. This is always done with an alloplastic material rather than a bone graft due to its simplicity and long-term predictability of volume and shape.

Amongst synthetic cranioplasty materials to use for forehead augmentation are the bone cements which include PMMA (methyl methacrylate) or HA. (hydroxyapatite) Each has their own advantages and disadvantages but the one difference that usually determines which one is used is cost. PMMA offers high volumes of material at a very affordable cost. HA is the more ‘natural’ cranioplasty material but its high cost usually precludes patients choosing it.

In the September 2013 issue of the Journal of Craniofacial Surgery an article was published entitled ‘Using Methyl Methacrylate for Forehead Augmentation for Aesthetic Purposes’. In this paper, the experience using an outpatient procedure for PMMA for aesthetic forehead contouring was reviewed over a 6 year period. In 210 patients, a limited incision scalp incision was made and PMMA material was placed and molded through the skin.  The amount of PMMA was only 10 to 40 grams with a mean amount of 25 grams. In following the patient an average time of nearly four years, most patients were satisfied with the results. The authors conclude that aesthetic forehead augmentation using methyl methacrylate is an effective surgical procedure with minimal side effects and a high degree of patient satisfaction.

While the use of PMMA for forehead augmentation is not new, this study is unique because of the limited incisional approach and the small volume of material used. This is really forehead augmentation for a small amount of increased forehead fullness or convexity. PMMA is the only cranioplasty material that can be used in this approach as it can be pushed through a small incision as a congealed putty mass and then shaped from the outside by hand. This is very similar to the approach I use for a minimal incision occipital cranioplasty.

What this study also shows is the safety of PMMA as an onlay cranioplasty material. While it is more of an ‘unnatural’ material than HA, its lack of bone bonding or bone ingrowth does not detract from its long-term successful and uncomplicated use.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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