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Archive for the ‘cranioplasty’ Category

Case Study – Temporal Skull Reconstruction with Hydroxyapatite Cement

Saturday, September 23rd, 2017

 

Background: Access to the brain and its lining requires the removal of part of he skull. Known as a craniotomy flap, the bone is usually removed in he shape of a semicircle or a full circle. Once the intracranial work is complete the bone flap is put back into place. But because the bone edges are vertical and a thin rim of bone at its perimeter has been removed in its creation, such bone flaps are well known to fall in or sink down creating an external bone contour deformity of the skull.

To avoid craniotomy flap sinking, plate and screw fixation is commonly used. A variety of differently shaped plates have been developed to rigidly hold the bone flap up as it heals. But despite such metal fixation, not all bone flaps always stay up as much as desired usually due to the failure of good bone healing across the surrounding bone flaps.

Treatment of a depressed craniotomy bone flap can be done by two fundamental approaches…either reposition the bone flap or leave it in place and contour on top of it. Both methods can be effective but employ very different technologies to perform.

Case Study: This middle-aged male had a left temporal craniotomy performed due to a traumatic injury and the need for treatment of a subdural bleed. Six months after the procedure, he had a very noticeable temporal depression that made him look like a piece of his head was missing from certain angles. The anatomy of his temporal depression was more than just the sinking of the bone flap, it was also due to the atrophy of the temporalis muscle as well.

Under general anesthesia the depressed bone flap was exposed through his original scalp incisions. It could be seen to be sunken in despite the use of plates and screws. The depressed bone flap had some mobility so a more rigid floor won top of the bone was created using a very shapeable hexagonal mesh material. On top of the mesh layers of hydroxyapatite cement was used to build up the bone contour including some compensation of the loss of muscle as well.

His after surgery results showed a much improved temporal and head shape contour. Because if the contouring capability of hydroxyapatite cement, one could argue that it is a superior approach than trying to reposition the bone flap in skull reconstruction particularly in the temporal region where muscle adds to its natural contour..

Highlights:

  1. Temporal craniotomy bone flaps can become depressed despite rigid fixation.
  2. One approach to craniotomy flap reconstruction is to leave the depressed bone flap in placed and build out the contour to the level of the surrounding bone.
  3. The combination of hydroxyapatite cement and a mesh floor  can be used to augment a depressed craniotomy bone flap.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Titanium Cranioplasty

Tuesday, July 4th, 2017

 

Reconstruction of the skull can be done using a variety of alloplastic materials. Over the years synthetic cranioplasties have evolved from solid metal plates to bone cements to computer-generated implant replacements of lost bone.  While some techniques are most historic than others, each still has a role to play in contemporary cranioplasty surgery.

When there js adequate time to have a 3D computer-generated implant reconstruction done, this is almost always the preferred method for large full-thickness skull defects. The strength of the materials (HTR, PEKK, PEEK) and their exacting fit makes them as ideal as possible for a non-autogenous reconstruction.

But when time does not permit the necessary fabrication time for a 3D implant, several alternatives exist. One option is that of bone cement. While there are several different types of bone cements, they will require a backing for their use in large full-thickness skull defects.  The hydroxyapatite bone cements, in particular, do not have enough strength when wet to resist displacement and potential fracture. Even with traditional PMMA bone cements, a rigid backing is still structurally beneficial

The best intraoperatively fashioned backing for full-thickness skull defects is titanium mesh. It comes in a variety of geometric configurations. But the hexagonal pattern allows for the most malleability of its shape and adaptation to the surrounding bone edges. It also has a lot of metallic  edges onto which bone cements can grab onto in the setting and curing process of the material.

While traditional metal cranioplasty refers to an outer solid cover over the defect, a mesh metal cranioplasty refers to its use as a backing for bone cement materials. If a mesh material is placed in the outer surface of the bone alone, tissue contraction around its mesh shape will eventually reveal these irregularities particularly in the exposed forehead area.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Forehead Reconstructive Implant

Monday, February 13th, 2017

 

Background: Reconstruction of the forehead is very different than aesthetic forehead augmentation. By definition reconstruction is required when a portion of the bony forehead has sustained a full-thickness bone loss. This most commonly occurs due to either trauma or the loss of a craniotomy flap after intracranial tumor surgery.

When rebuilding the forehead that has sustained bone loss, the most common method today is to use a 3D implant. From a 3D CT scan an implant can be designed and fabricated out of various polymeric materials. The precision fit, smoothness of the outer contour and the shortened operative times makes a custom forehead reconstructive implant usually preferred over an autologous bony reconstruction.

Such synthetic forehead reconstructions, however, may be done with good vascularity and thickness of the overlying soft tissues. If the patient has had prior irradiarion or been exposed to multiple reoperative surgeries, the soft tissue quality must be changed rpior to any implant placement. In addition, no portion of the implant should encroach on the frontal sinus cavity space or should have a prior frontal sinus obliteration. In essence forehead bone implants work well when the tissues around them can support them and be resistant to infection.

Fat Injections to Forehead Craniotomy Defect technique Dr Barry Eppley IndianapolisFat Injections to Forehead Craniotomy Defect left oblique view Dr Barry Eppley IndianapolisCase Study: This 55 year-old female had a large central bony defect from multiple intracranial surgeries for recurrent gliomas. She lost her frontal craniotomy bone flap from an infection coming from the frontal sinus/nose several surgeries ago. She ultimately had a vascularized ALT fascial flap placed to cover the dura which was secondarily augmented above it by fat injections due to the thinness of the forehead skin. While much of the injected fat graft was lost by volume, some survived and its effects on the soft tissues further improved the quality of the forehead skin.

Forehead Bony defect model Dr Barry Eppley IndianapolisCustom Forehead Implant Reconstruction intraop Dr Barry Eppley IndianapolisHer large forehead bony defect could be appreciated in a model made of it. A custom forehead reconstructive implant made of PEEK (polyetheretherketone) polymer was finally placed to create a permanent forehead contour restoration. At the time of its placement areas of fat globules could see on top of the ALT fascia over the dura as well as on the underside of the forehead skin. The implant had a perfect fit and was secured with small plates and screws.

3D forehead reconstruction with a computer generated implant sounds high-tech, and it is, but failure will ensue if the soft tissue around it is not of good quality.  The quality of the tissue bed into which the implant will lie can not be improved any form of computer technology. The surgeon must ensure that the tissues can tolerate a synthetic bony implant and all sources of infection are resolved before a custom forehead reconstructive implant is placed.

Highlights:

1) Forehead reconstruction with any form of an implant requires well vascularized and adequately thick overlying soft tissues

2) Restoring forehead tissue thickness can be done using either fat injections or a vascularized free tissue transfer.

3) A custom forehead reconstructive implant made of PEKK material can be placed after the forehead has had its soft tissue quality improved.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – 3D Forehead Reconstruction Implant

Tuesday, February 7th, 2017

 

Forehead reconstruction encompasses a variety of inlay and onlay bone procedures. Reconstruction of full-thickness frontal bone defects most commonly occurs from either neurosurgical procedures where a craniotomy bone flap has been lost or from skull bone loss due to trauma. While replacing the lost bone can be done by using the patient’s own bone, this is very much like ‘robbing Peter to pay Paul’. A large segment of full-thickness skull bone must be taken from another location on the skull, split into two halfs and then both skull defect sites have to be reconstructed with the bone segments.

As a result, the most common method for full-thickness skull bone loss is a synthetic material. There are a variety of implant materials available for use, but the use of 3D imaging and computer design dominates how such forehead bone reconstructions are done today. The precision fit of a 3D implant design made of a strong implant material is appealing for both surgeon and patient alike.

Custom Forehead Skull Implant Reconstruction Dr Barry Eppley Indianapolis3D forehead reconstructive implants can be made of metallic titanium, HTR polymer, PEEK and PEKK materials. Using a 3D CT scan the implant is prefabricated and usually fits with little modification needed. (often no adjustments of the perimeter of the implant are needed) This is an example of a 3D  forehead reconstruction implant made from PEKK material to replace a lost frontal bone flap due to infection from a prior intracranial tumor resection procedure.

PEKK is a synthetic polymer composed of polyetherketone ketone material. It is firm implant material that has a a high resistance to fracture. In addition it has a lighter weight than other materials like titanium. Its lightweight, high impact resistance and being able to be laser sintered in fabrication make its an excellent 3D cranial implant.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Bone Cement Cranioplasty

Saturday, May 28th, 2016

 

Background: The external shape of the head is a direct reflection of the form of the skull underneath it. While skulls can have various sizes and are made up of multiple cranial bones, a smooth and convex shape is desired no matter from what angle it is viewed.

Men make up a greater portion of skull reshaping patients than women. This is a direct result of exposed scalp surfaces from men who have shaved their head or have little hair density or length to cover it. Women can better camouflage skull irregularities because of their usually better hair density and growth.

Prior skull surgery or cranioplasty efforts can leave a skull shape that is asymmetric or irregular. While the skull surface may appear smooth at the time of surgery, healing and scalp adaptation may eventually reveal even the most minor skill irregularities.

Case Study: This 45 year-old male presented with a desire to improve the shape of his head. He had a history of prior skull surgery and cranioplasty efforts, of which the initial origin of these efforts remained unclear. He reported that ‘bone cements’ had been used in the past.

Under general anesthesia and through his existing coronal scalp incision from ear to ear, his entire skull surface was exposed. There was a form of bone cement (which appeared to be Kryptonite from my experience) at various locations on his skull. Its application was irregular and not smoothly applied. A handpiece and burr was used to reduce and smooth out all existing bone cement areas. Application of new bone cement (PMMA) was used to fill in any depressed skull areas.

Revision Skull Reshaping result front view Dr Barry Eppley IndianapolisRevision Skull Reshaping result back viewHis results six months later shows a much smoother and convex skull shape. His case illustrates that no matter how thick the scalp may appear any irregularities of the skull will eventually be seen. Applications of bone cements on the skull must be smooth and feathered into the surrounding bone to avoid visible irregularities.

Highlights:

1) The shape of the head should be smooth and convex from all viewing angles.

2) Many skull contour irregularities can be satisfactorily treated by the application of bone cements

3) There are different types of bone cements used in cranioplasty which differ in material and cost but not in effect.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Custom Occipital Skull Implant

Wednesday, March 30th, 2016

 

Background: Deformities of the back of the head, or of the occipital skull, are not uncommon. Due to the back of the head being exposed to pressures in utero and after birth, occipital deformation is the most frequently occurring skull shape alteration. While known to occur in certain ethnic groups (e.g., Asians) more than others, it can affect any race or gender.

While some back of the skull deformities bother people even with full heads of hair, hair loss/thinning can make the skull concern more apparent.  This takes on heightened significance in men who who are bald and shave their heads. Thus it should be no surprise that men make up an equal if not greater portion of patients that seek skull reshaping.

Many occipital skull deformities are marked by flattening that is often asymmetric. This is far more common than perfectly symmetric flat back of the heads. This underscores the importance of creating a custom skull occipital implant from a 3D CT scan. No intraoperative skull augmentation method can come close to the precision of 3D implant designing.

Custom Occipital Implant design for asymmetry Dr Barry Eppley IndianapolisCase Study: This 45 year-old male was bothered by the flatness on the right side of the back of his head. Even though he had a good head of hair, he had long been concerned about it. From a 3D CT scan, a custom occipital skull implant was designed that rounded out the back of his head for a more symmetric shape

Under general anesthesia in the supine position, a 7 cm horizontal scalp incision was made low on the back of the head. Through this incision, a wide subperiosteal dissection was made that extended beyond the edges of where the implant would go. The custom occipital skull implant, after preparation by making multiple perfusion holes, was rolled and inserted. Once the implant was completely inside it was unrolled and positioned into its proper orientation as designed on the 3D CT scan. The scalp incision was closed in multiple layers with dissolveable sutures.

Occipital Skull Implant Dr Barry Eppley IndianapolisOccipital Skull Implant result back view Dr Barry Eppley IndianapolisOccipital Skull Implant incision Dr Barry Eppley IndianapolisHis one day after surgery results showed a significant improvement in the size and shape of the back of his head. His recently made incision remained invisible inside his uncut and shaved occipital hairline.

A custom occipital skull implant is the best method for correction of an asymmetric back of the head shape. As long as the goal is to need just enough augmentation to make the back of the head more symmetric and smoother, the overlying scalp tissue should stretch sufficiently to cover the implant without undue tension on the incision closure.

Highlights:

1) Custom skull implants have become the gold standard for correcting many types of skull shape issues.

2) Made from a 3D CT scan, the implant can be designed to match an asymmetric side of the skull to the other more normal side.

3) Because custom skull implants are flexible, particularly the thinner they are, they can be inserted through small scalp incisions.

Dr. Barry Eppley

Indianapolis, Indiana

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.

Highlights:

  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.

Highlights:

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.

Highlights:

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


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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