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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘occipital augmentation’

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

Plastic Surgery Case Study: Occipital Bone Augmentation with Neck Fat Injections

Saturday, December 6th, 2014


Background: One of the most common aesthetic skull deformities is a flat back of the head. Caused by either genetics or external deformational forces in utero or after birth, the lack of adequate projection in the occiput can be aesthetically disturbing to some people. While often camouflaged by hair, it can still be a concern and is even more so by men who shave their heads or have very short hair.

Like forehead augmentation on the opposite side of the skull, occipital augmentation can be done by a variety of materials and techniques. By far the best occipital contouring technique is the use of a custom implant made from the patient’s 3D CT scan. This has become a very popular method used today due to its prefabrication of shape and thickness as well as the ability to limit incision size. But not everyone can use a custom implant approach for a variety of reasons. In these cases the traditional technique of implanting PMMA bone cement is used with intraoperative shaping and contouring is done. This requires no presurgical lead or fabrication time.

Back of Head AnatomyDespite the success of occipital augmentation surgery, some patients would like the augmentation to extend lower. Without realizing it their desired zone of enhancement is off of the bone and onto the neck muscles. Most people do not realize that the bottom end of the occipital bone (nuchal line) is at the level of the upper 1/3 of the ear. Thus bone cements can not be extended that low. Any augmentation below this back of the head level (which is not that commonly requested) must be done by soft tissue augmentation methods.

Case Study: This 26 year-old male had been bothered by his flat back of the head since he was a teenager. In determining his back of the head augmentation goals, which he provided by drawings, it could be seen that he wanted an augmentation effect that went below the nuchal line.

Fat Injections Neck Dr Barry Eppley IndianapolisUnder general anesthesia, a 9 cm curved incision was made at the upper back of the head. From this approach, wide subperiosteal undermning was done over the entire back of the head down to the nuchal line. Using 60 grams of antibiotic-impregnated PMMA bone cement, it was applied on the back of the head and the scalp flap was used to shape it as it set. Once the scalp incision was closed, small cannula liposuction fat harvesting was done from his lateral thighs. (his preferred choice) The 120cc lipoaspirate was concentrated down to 30cc which was then injected into his posterior neck at the subcutaneous level below the nuchal line down to the bottom of the hairline.

Occipital Skull Augmentation with Neck Fat Injections result Dr Barry Eppley IndianapolisMore complete occipital augmentation requires a hard and soft tissue approach. The use of fat injections is the only method for augmenting the lower portion of the flat back of the head. It may not be as reliable as bone cement for a permanent augmentation effect but it can be placed with an injectable technique. It can provide some moderate volume to complement a more profound upper occipital augmentation.

Case Highlights:

1) Occipital (back of the head) augmentation can be done by a variety of materials of which PMMA bone cement is the most economical.

2) The extent of occipital augmentation ends inferiorly near the nuchal line at the base of the skull which lies roughly at the level of the top of the ear.

3) Augmentation below the nuchal line must be done with fat injections over the neck muscles.

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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