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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘flat back of the head’

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

Case Study – Flat Back of the Head Correction with Custom Occipital Implant

Friday, February 27th, 2015


Flat back of head Dr Barry Eppley IndianapolisBackground: The most common aesthetic skull deformity is that of the flat back of the head. This occurs most commonly from in utero or postnatal infant positioning and also has a strong genetic tendency amongst certain ethnic groups. (e.g., Asian)  While a flat back of the head has no detrimental intracranial or neurologic effects, it can be very psychologically bothersome to some people. To those so affected, it causes a variety of efforts at hairstyle and hat management to camouflage the shape of the skull.

A variety of augmentation procedures have been done over the years for the flat back of the head deformity. It is merely a question of what materials have been used, how they are shaped and what type of incisional access is needed to do so. Injectable materials like synthetic fillers and fat, while appealing, simply do not work. The scalp is not like the face, breasts or buttocks. It is much stiffer and has no real fatty layer into which filler materials be easily placed. While some injected fat may survive, it runs a high risk of being irregular and can never create much overall volume augmentation.

Bone cements have been the most popular skull augmentation materials. While they can be effective they require fairly long scalp incisions to properly place and shape them. When placing them through smaller incisions they run the risk of palpable irregularities and edge transitions. The kocation of the incision is often needed right near or over the cement application which potentially poses a healing issue when the scalp closure is very tight.

In my practice, bone cements have largely given way to custom skull implants made from the patient’s 3D CT scan. This method offers significant advantages including a precise shape and thickness augmentation, a much lower risk of edge transition and irregularities, shorter operative times and a scalp incision that is located away from the implant’s maximal tension of the overlying scalp

Case Study: This 30 year-old female had long been bothered by the flatness at the top of her head. She styled her hair to puff it up in the back to add volume to the back of her head. She finally wanted a more definitive and permanent solution. She did have a very pertinent prior cosmetic surgery history having had a strip graft harvest from the back of her head for hair transplantation to lower her frontal hairline.

Custom Occipital Implant design Dr Barry Eppley IndianapolisCustom Occipital Implant design 2 Dr Barry Eppley IndianapolisA 3D CT scan was used to design a silicone occipital implant to cover the back of her head. Its maximal thickness was 12mm in the central projection area. Because of her prior hair transplant, she had lost at least 1 cm of scalp flexibility. The thickness of the implant was kept to 12mm to ensure that it would fit without undue tension on the scalp incision and also not to compromise the blood flow to the central scalp over the implant.

Cusytom Occipital Implant Dr Barry Eppley IndianapolisIncision for Custom Occipital Implant Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, her prior hair transplant scar was used for access. At the tail end of the incisions the occipital neurovascular bundles were identified and preserved. Long curved instruments were used to develop a subperiosteal pocket around the curved contours of the back of the skull. The custom implant was prepared by placing multiple perfusion holes using a 2mm punch. It was fairly easily inserted, positioned and the scalp incision closed with some tension.

Custom Occipitgal Implant in Female result side view Dr Barry Eppley IndianapolisA custom skull implant for a flat back of the head offers the most predictable outcome with the lowest risk of complications or need for revisional surgery in my experience. Designing the implant shape and thickness that the scalp can tolerate is the ‘art’ in the process and that will differ somewhat for each patient. Some patients will find that the amount of augmentation may be less than they desire as a single stage procedure. If one desires much larger amounts of occipital augmentation, a two-stage approach can be done with a first stage scalp tissue expander.

Case Highlights:

1) Custom designed silicone implants are the most effective method for augmentation of the flat back of the head.

2) The size and thickness of a custom occipital implant is controlled by the incisional access and how much the scalp will stretch to accommodate the thickness of the implant

3) It has been my experience that 12mm to 15mms is as much implant thickness that can be placed on the back of the head.

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

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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