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Dr. Barry Eppley

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Posts Tagged ‘occipital implant’

Case Study – Semi-Custom Implant for Occipital Plagiocephaly

Wednesday, June 10th, 2015


occipital plagiocephalyBackground: Occipital plagiocephaly is a well recognized skull shape deformity that is caused by deformational forces. Whether this is the result of intrauterine constraint, post delivery head positioning or both, the thin and malleable skull bones are prone to be inadvertently molded into a deformed shape. This classically appears as a flatness on one side of the back of the head with some protrusion of the opposite side and a well described entire craniofacial scoliosis of varying degrees.

While cranial molding helmets can be very effective at the treatment of deformational occipital plagiocephaly, their effectiveness diminishes after 12 to 18 months of age. Once this non-surgical treatment window has passed, surgery is the only effective treatment. But the concept of surgically taking off the entire back of the head and reconstructing it can be too invasive for many patients and is only appropriate in the most severe occipital flattening cases. As an adult, however, bony reconstruction is not an option given the thickness of the skull bones and the sheer magnitude and risks of major skull reshaping surgery.

Flatness of the back of the head in adults is an often unrecognized aesthetic concern. But to the patient so affected it is well recognized with many maneuvers done to camouflage it from hair styles to hats. Correction of a unilateral occipital plagiocephaly in adults is most effectively and simply done using an implant that is placed on the bone. This type of occipital implant can be done using either custom or semi-custom designs. The surgery to place them remains the same regardless of how the implant is made.

Case Study: This 25 year-old male wanted to improve the shape of the back of his head. He had a significant of the right side of the back of his head which was the direct result of how he slept as an infant. He had all of the typical associated findings with it including a more forward positioning of the right ear (ear asymmetry), some mild left occopital protrusion and other more skull shape changes. He was offered the choice of having a 3D CT scan done and a custom implant made for it or to use an existing right occipital implant (from a custom implant made from another patient) instead. (what I call ‘semi-custom’ implant) Due to economic considerations, he chose a semi-custom occipital implant design.

Unilateral Occipital Implant for Plagiocephaly Dr Barry Eppley IndianapolisUnder general anesthesia and in the prone position, a 9 cm long horizontal incision was made in the low occipital hairline over the nuchal ridge. A full thickness scalp flap off the bone was raised in a wide manner around where the implant would be positioned on the bone. The implant was inserted and positioned so that the thickest portion was over the flattest occipital skull area.

Occipital Implant Results for Plagiocephaly Dr Barry Eppley IndianapolisOccipital Implant Results oblique view for Plagiocephaly Dr Barry Eppley IndianapolisAs would be expected, the change to the back of the head was instantaneous right after the implant was placed. While the maximum degree of occipital symmetry was not obtained due to using a semi-custom (not designed for this specific patient), the degree of improvement was remarkable nonetheless.

A semi-custom occipital implant offers a cost-effective approach to treatment of occipital asymmetry due to congenital plagiocephaly. It is successful because the shape of the skull deformity is fairly predictable and the thickness of the scalp provides some forgiveness for edge-transitions.


  1. Unilateral occipital plagiocephaly can be effectively treated as an adult by the placement of an implant for skull reshaping/augmentation.
  2. Unilateral occipital implants can be custom made or a semi-custom type implant can be used.
  3. An occipital implant for a flatness on one side of the back of the head is placed through a low occipital hairline incision.

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

Case Study: Custom Occipital Implant For Flat Back Of The Head Deformity

Wednesday, July 9th, 2014


Background: Skull shape deformities are not typically perceived as an aesthetic problem. But just because they are not common does not mean they are not just as significant to someone who has it nor that they can not be improved satisfactorily. There are a wide range of aesthetic skull deformities that affect its entire length from the forehead back to where the neck muscles attach to the bottom end of the skull.

Flat Back of the Head Dr Barry Eppley IndianapolisOne of the most common aesthetic skull deformities is that of the flat back of the head. Occurring from either in utero or neonatal positioning the back of the head can suffer a non-neurologic deformation, ending up with a variety of flattened shapes. This flattening may or may not be associated with compensatory widening of the parietal bones creating flaring or widening in the back with the flat spot in between the two sides. (known as brachycephaly) While this can occur in anyone under the right circumstances, the Asian population is particularly prone to occipital flattening. This may be due to inherent development patterns in which front to back skull growth is naturally shorter.

While to the uninformed, flatness on the back of the head may be perceived as trivial and easily covered by hair. Nothing is further from the truth to someone who has it. I have heard many stories from patients abut the time and effort they put into styling their hair to camouflage it or from men who constantly wear hats to keep it covered. For some men what was once something they could feel, losing their hair begins a process of exposure of their flat back of the head and can serve as tbe the stimulus to seek a surgical solution.

Custom Back of Head Implant design Dr Barry Eppley IndianapolisCase Study: This 42 year-old Asian male had always been bothered by the flat spot on the back of his head. He routinuely spent time with gel products making his hair stand up in the back for camouflage. The flatness of the back of his head could be seen in a 3D CT scan with a severe drop-off from the top of the skull down. From this scan, a custom silicone implant was designed to cover the flat area with a central thickness of 8mms. He also had occipital asymmetry with the right side having a greater degree of flatness in which the design compensated by more material on that side.

Custom Occipital Implant Perforations Dr Barry Eppley IndianapolisCustom Occipital Implant Placement Dr Barry Eppley IndianapolisUnder general anesthesia, he was turned into the padded prone position. A horizontal 4.5cm incision was made low in the occipital hairline just below the nuchal ridge. Dissection was done down to the bone and wide subperiosteal undermining was done with long curved dissectors beyond where the implant edges would be in a 270 degree radius from the incision. The implant was prepared by making multiple ‘perfusion holes’ through it with a 3mm dermal punch. It was then folded for insertion, unfolded once inside, positioned and then secured with a single 1.5mm self-tapping screw at its lower edge.

Custom Occipital Implant results side viewThe effects of the implant were immediate and no edge-transitions could be felt. The incision was closed in two layers with small resorbable sutures for the skin. He had some mild pain the first night but took no narcotic medications after the first 24 hours. He looked very ‘non-surgical’ the next day.

Having performed occipital augmentation with various materials, there is no question that using a custom silicone implant is the simplest approach. By its prefabricated design and the smooth silicone material, it is also the most assured way to avoid any palpable edge transitions of the implant to the bone. The placement of perforating perfusion holes allows for multiple points of fibrous fixation that will ensure that the implant will never move or migrate despite its smooth surface. Such holes also prevent any flexing of the implant in an area like the back of the head where it encounters frequent pressure when laying. (although this is more likely to happen in a non-custom implant that does not have a perfect fit.

Case Highlights:

1) Augmentation for the flat back of the head can provide a significant aesthetic improvement.

2) A custom occipital implant made from the patient’s 3D CT provides the most accurate fit for the flat back of the head.

3) A custom implant can be placed through a low horizontal skin incision at the base of the neck, which may be particularly advantageous in men,

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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