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Posts Tagged ‘occipital cranioplasty’

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

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

Case Study: Flat Back of the Head Correction by Augmentation Cranioplasty

Friday, August 9th, 2013


Background: The shape of the skull is affected by numerous factors including genetics, in utero skull pressures, post delivery head positioning and growth of the brain. In general, the skull has an oblong shape that is slightly wider in the back than the front. While there is no uniform aesthetic standard for a pleasing skull shape, there are certain skull shape abnormalities which are acknowledged to be undesireable.

One of these undesireable skull shapes is the ‘flat back of the head’. It can be seen as either flatness on just one side (plagiocephaly) or that the entire back of the head is flattened. (brachycephaly) Even in patients that have full heads of hair, these occipital deformations can be disconcerting. Patients frequently use various hair style manuevers to create the illusion of an expanded skull contour. In those with poor hair density or who shave their heads, the magnitude of the occipital skull depression can be very visible.

Correction of the flat areas on the back of the head can be done by a procedure known as an onlay cranioplasty. In essence this is the application of a synthetic material on top of the flattened skull bone to change the shape of it. Synthetic cranioplasty materials, such as PMMA and hydroxyapatite bone cements, can be applied and shaped to create an expanded and more rounded form. The key to a successful aesthetic cranioplasty is the length and location of the incision, the volume of material that can be added (based on how much the scalp can stretch) and the formed shape of the augmentation.

Case Study: This 28 year-old Asian male desired the width of his temporal skull reduced and the flatter occipital dome built up. He had very large temporal muscles which created significant convexity in the area above the ear forward to the eye. He also had a flat spot directly on the crown of his head. (crown flatness)

Under general anesthesia in the beach chair position (45 degree chair position), a transcoronal incision was made from just above one ear to the other. This enabled the scalp to be reflected in a ‘clamshell’ fashion. The temporal muscles were released along their posterior and superior attachments along the temporal line down along the side of the forehead. The temporal muscles were released, resected and reattached with miniature screw through the fascia in a much more anterior and inferior position. Posteriorly the flattened occipital crown had a 60 gram PMMA onlay augmentation done with microscrew anchorage. The scalp was then closed with resorbable sutures for the skin with larger resorbable sutures for the deeper galeal layer.

When seen six months later, his results showed an improved occipital skull profile and  a substantially reduced bitemporal distance.

One important issue to assess in any aesthetic cranioplasty surgery is how did the scar heal. His scalp scar results showed a remarkably discrete scar that was hard to find…a result that I like to see in any scalp scar particularly in men where hair camouflage may be harder to come by.

Case Highlights:

1) Augmentation of the flat back of the head is one of the most common request for aesthetic cranioplasty. (cosmetic skull reshaping)

2) Occipital cranioplasty is done through the onlay application of either PMMA or HA on the outer skull surface.

3) One can expect to achieve up to 15mm to 20mms of augmentation in the central arc of the occipital expansion dependent upon how much the scalp will stretch to accommodate it.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Two-Stage Approach for Large Augmentation Onlay Cranioplasty

Tuesday, July 2nd, 2013


Background:  While there are many different cosmetic skull shape deformities, one of the most common is that of a flat back of the head. The slope of the back of head can be flat either in a completely vertical plane (lack of posterior projection) but most commonly is more of an exaggerated slope from the top of the vertex to the back. (lack of posterosuperior projection) These are the result of deformational skull forces either during utero or early after birth due to positioning.

Patients so afflicted can suffer some significant psychological distress from the flat shape of their skull. They may constantly wear hats or other head garments or style their hair to camouflage it. (hair pulled up and over the flat part of the skull in a ponytail) In some women they may wear a plastic device known as a ‘bumpit’ which is placed under the hair to create a much higher hair height due to a lack of bony skull projection

The skull can be built up by bone cements anywhere on its bony surface. This is a common surgical method for a variety of skull deformities. But the amount of skull augmentation that can be achieved is limited by how much the overlying scalp can stretch. It is important in any expansile cranioplasty to have a scalp closure over the material that is not unduly tense (too tight) to avoid potential wound problems after surgery. For most patients this amounts to about 60 grams of bone cement and not usually much more than that can be safely applied.

To overcome the concerns about scalp expansion during a cranioplasty or for the patient who wants the maximum amount of skull augmentation, a two-stage cranioplasty needs to be performed. In the first stage, a tissue expander is placed into the scalp and then expanded by saline injections into it every few days. Expansions on done for 4 to 6 weeks after placement based on how much scalp stretch is needed. At the second stage, the tissue expander is removed and up to 120 to 150 grams of bone cement can be placed with an assured tension-free closure.

Case Study: This 26 year-old female was bothered by the lack of height in the back of her head. She usually wore her hair up to hide the flatness. She was very motivated to gain skull height and did not feel that what could be opened in a single-stage cranioplasty would be adequate. She wanted the maximal height obtainable like an internal ‘bumpit’.

Under general anesthesia, a left posterior vertical temporal incision was made. This enabled blunt dissection to be carried out across the entire scalp on the back of the head. Through this incision, a scalp expander was inserted with the dimensions of 10 x 6cms. The remote port was passed under the scalp and under the temporal skin just above the right ear. Beginning 10 days later at home, she inflated the expander to 200cc using small needles and sterile saline over a time period of six weeks.

During a second stage procedure (six weeks later), the existing right temporal incision was extended across to the other side. The tissue expander was exposed and removed. The capsular scar tissue was removed off of the bone so good contact could be obtained between the bone and the cement. Three 1.5mms titanium screws of 7mms were initially applied to the very back of the head. Then 60 grams of PMMA bone cement was mixed, applied, shaped and allowed to set. Two more 1.5mms screws were applied in front the set material and an additional 60 grams was applied on top and in front of the previous application. After the second application of the material was set, a drain was placed and the scalp closed over it with dissolveable sutures. A circumferential head wrap was placed as a dressing.

Her recovery showed some typical scalp swelling but this was really not hat noticeable given the height of the augmentation. The drain was removed the next day. The amount of augmentation was very much like having an internal bumpit placed on the skull, if not more.

A two-stage skull augmentation can be completed over a six-week time period and can usually double the amount of cranioplasty material that can be safely appled.

Case Highlights:

1) A flat sloping back of the head is a common cosmetic skull deformity. Many people style their hair to either hide it or make the back of the head look bigger.

2) An augmentative onlay cranioplasty can be done to build up the back of the skull but the amount of augmentation is limited by the stretch of the overlying scalp.

3) To achieve maximal skull augmentation, a two-stage skull augmentation can be done by a first-stage scalp tissue expansion.

Dr. Barry Eppley

Indianapolis, Indiana

Occipital Onlay Cranioplasty For Correction Of A Flat Back Of The Head

Friday, December 21st, 2012


Cosmetic skull deformities encompass a wide variety of concerns from flatness, pointy or high spots, ridges, bulges and asymmetries. But one of the most common head shape concerns is the flat back of the head. This specifically refers to varying degrees of lack of occipital projection, usually occupying an area between the top of the skull in the back down to the horizontal level of the upper portion of the ear. The causes are well known as a minor variant of occipital brachycephaly and often develop from early infantile positioning.

While flatness of the back of the head may seem trivial, to some affected it represents a significant aesthetic concern. The lack of a round posterior cranial shape is hidden by those concerned with caps and hairstyles and even devices that make the hair have more projection.  Some refuse to go swimming so their hair is not flattened to reveal an absent occipital roundness. Others feel their ‘flat head’ make them look unattractive and facially disproportionate.

The flat back of the head can undergo aesthetic improvement by a skull reshaping procedure known as an augmentation cranioplasty. Using either a plastic or hydroxyapatite material, an improved occipital shape can be obtained by building up the bony contour. Either material is applied in a putty-like state and manually shaped to the desired form until firmly set. Depending upon the incisional access and the amount of surgical exposure, the amount of cranial expansion can be up to 15mms to 20mms of augmentation if a competent scalp closure can be obtained.

A unique feature of most augmentation onlay cranioplasties, regardless of their location, is that the material must be applied to a smooth round surface. In addition, these round skull surfaces offer no inherent stability with most of their locations being the equivalent of on the ‘side of a cliff’.  As no known onlay cranioplasty material truly integrates into the underlying bone (or bone grows up into the implanted material), engagement of the material onto the skull’ surface has benefit. This is most conveniently done with small screw fixation.

Screw fixation of onlay cranioplasties, however, is not done as one envisions it for other facial implants. The implanted material is not first applied and then secured into position by screws. This is how it is done for preformed implants. Onlay cranioplasties are formed after they applied. Thus screws are initially placed and serve as a means of anchoring or something for the material to grab onto once applied, like metal rebar in concrete. This is particularly useful in occipital cranioplasties in which the material must be applied on the vertically-oriented back of the head where slippage and material displacement is very likely.

The pre-material placement of screws in onlay cranioplasty is useful for more than just implant anchorage. They are also helpful in setting the thickness of the applied material. By placing screw with lengths for the amount of thickness desired, the material can be applied using the screws as contouring guides.

Occipital cranioplasty can provide significant cosmetic improvement to those afflicted with a flat back of the head. Modern biomaterials such as titanium screws and acrylic and hydroxyapatite composites can very effectively create a more aesthetically pleasing occipital contour.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Cranioplasty for the Flat Back of the Head

Monday, July 23rd, 2012

Background:  The shape of the head is largely determined by the skull that lies underneath it.  Its normal oblong shape is created by the multiples plates of skull bone formed in utero that only formally fuse together after birth. The rapidly developing and expanding brain has great influence on forming the skull shape, much like an internal tissue expander.

But if the bone is blocked from being expanded, it will result in the push of the brain being directed elsewhere. This blocking effect can be created by a suture fusion (craniosynostosis) or an external force. By far, the most common cause of skull asymmetry is external molding. The most frequent form of external molding is inadvertent pressure caused by laying on one side of the head too long as a baby. This causes a classic flattening on one side of the back of the head with compensatory overgrowth on the other side. This is known as occipital deformational plagiocephaly.  On careful examination, one can often see from above that the entire head is twisted or rotated causing a cranioscoliosis effect in more severe cases.

With today’s shorter hairstyles and shaved heads, bothersome flat spots on the back of heads are becoming more evident. Often the ear on the flat side is moved further forward than the opposite ear and even the neck muscles on the flat side are asymmetric to the other side. These posterior skull asymmetries have given rise to patient’s requesting if they can be improved by some form of plastic surgery.

Case Study: This 42 year-old man was extremely bothered by the flat spot on the left side of back of his head. He had shaved his head for years since he began balding. To hide his concern about his flat spot, he always wore a hat to camouflage it. In discussing the option of a craniplasty correction, the issue of the trade-off of a fine scar was discussed. His level of concern about the back of his head made the scar issue a palatable exchange.

Under general anesthesia, a 9 cm horizontal posterior scalp incision was made. Wide exposure was made of both the normal and flat side of the occiput. Two small 1.5mm screws were placed at two different levels of the flat side marking how high the augmentation had to be for symmetry. Then using a PMMA acrylic cranioplasty material of 30 grams impregnated with antibiotic powder, a putty was made and inserted through the incision onto the flat occiput. The material was shaped through a combined internal and external methods until the area was both augmented and smooth and all edges were feather-like. The material set in ten minutes and the incision was then closed. A circumferential head dressing was applied and no drain was used. The length of the surgery was 90 minutes.

He had only minor discomfort the first night surgery and none thereafter. His head dressing was removed the next day. He had some expected swelling but no pain. Dissolveable sutures were used so removal was not necessary. He was placed on no restrictions after surgery and he could shave his scalp around his incision site 48 hours after surgery. His degree of occipital symmetry was dramatically improved.

Correcting a flat spot on the back of head is no different than a frontal or forehead augmentation. It is an onlay cranioplasty that requires a biocompatible material and an incision to place it. Scars are made as small as possible and material options are either an acrylic PMMA or HA. (hydroxyapatite) Cost plays a role in material choice. How much skull symmetry can be achieved is largely based on the volume added. The limiting factor in how much volume can be placed is scalp tightness and getting a good incision closure, preferably not directly over the implanted material.

 Case Highlights:

1)      One of the most common skull deformities is flattening on the back of the head, also known as occipital deformational plagiocephaly.

2)      Building up the flat back of the head is done by an onlay cranioplasty procedure, using a variety of different materials.

3)      Using an open approach, an occipital cranioplasty procedure is both very effective and involves minimal recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Cosmetic Skull Augmentation of the Flat Back of the Head

Tuesday, July 26th, 2011

When one thinks of cosmetic surgery, the thought rarely goes to any form of skull contouring. While the world is full of a wide variety of head shapes, there is no uniform size or measurement to determine a pleasing cranial contour. But there is a certain oblong and curvilinear shape to most of the skull. The forehead, which is really the front part of the skull, has some very specific desired shapes and contours that are very gender-specific, but the rest of the skull has less well-defined determinants of being pleasing in appearance.

Despite the comparatively obscure location of the back of the head (occiput) compared to the forehead, not everyone is entirely pleased with this portion of their skull shape. The typical concern is that the back of the head is too flat without adequate projection. Whether it be the entire occiput or limited to just the crown area (upper occiput), this is a legitimate cosmetic concern for those so affected. For anatomic clarification, the bony portion of the occiput actually stops at about the level of the middle of the ear. The rest of the back of the head is muscle and other soft tissue.

The most effective method of occipital skull contouring is augmentative, putting a material on top of the bone to build it out. This is a common form of cranioplasty that has a long history in the forehead, it is just less commonly done on the back of the head. There are multiple ways to perform an occipital augmentation cranioplasty and they differ primarily in the material used and the incisional approach to get it there. Each has their own distinct advantages and some disadvantages.

The open form of an occipital cranioplasty involves a transverse incision of about 8 or 10 inches on the upper part of the back of the head. This approach heals better than any other scalp incision in this area. The scalp is lifted off of the bone around a premarked area of the flattening. Through this approach, either an acrylic (PMMA) or calcium hydroxyapatite (HA) material can be mixed, placed and contoured to the desired shape. Both are powders and liquids that are mixed together to form a moldable putty which as about 10 minutes of working time. Because it is a putty, thus is why it needs an open approach to be placed. Acrylic has the advantage of setting up as solid as bone and just as fracture-resistant. That would offer a theoretical advantage on the back of the head since we lay on it all the time. HA, which setting up firm, is a bit more brittle and fracture-prone although I have never seen that to be a problem in the forehead. With either material, the open approach offers the best chance for a very smooth and even contour shape.

The limited incision approach uses a three to four inch incision through which the materials are ‘pushed’ through as a putty and molded from the outside as it sets. The only cranioplasty material that has the physical properties once mixed (for the first 12 minutes) to be a good moldeable putty is PMMA or acylic.The disadvantage to the limited incision approach is that there is a higher risk of contour irregularities and palpable edges. This occurs because the molding of the material as it sets is done from the outside so there is no visual way of confirming how smooth it is as it sets.

Cosmetic contouring can be done on most areas of the skull. Occipial augmentation cranioplasty can be done to build out a flat spot or entire back of the head. Regardless of the material and the incision used, it is a simple procedure for a patient to go through with very minimal recovery. Patients report having a headache for a few days but no real pain. Once can wash their hair within 48 hours. Some mild swelling can be expected and the final result can be fully appreciated within 6 weeks after the procedure. All of the cranioplasty materials used are permanent so the change in skull contour will be maintained over one’ lifetime.

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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