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Dr. Barry Eppley

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Surgeon Dr. Barry Eppley

Posts Tagged ‘occipital plagiocephaly’

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

Correction of Facial Asymmetry in Adults from Occipital Plagiocephaly

Monday, October 19th, 2009

Occipital plagiocephaly is a well known congenital malformation of the back of the head marked by an oblique slant to the main axis of the skull. It is commonly corrected today by the early institution of either static or dynamic cranial orthotics or helmets. In rare cases if the skull is significantly deformed and does not respond to external molding influences, cranial reshaping can be successfully done.

Plagiocephaly is well known to affect how the face develops. What happens in the back of the skull will influence how the front of the skull and face looks. This occurs in a diametrically opposite manner. The side that is flat on the back of the head will be protrusive on the front….and vice versa. Even in cases where helmet therapy or even surgery has made a well rounded back of the head, the face may still show some of the residual effects as it develops resulting in facial asymmetry. When plagiocephaly goes untreated or was not adequately treated at a young age, this facial asymmetry may become quite apparent.

The facial asymmetry that results from a plagiocephalic influence appears as that of a ‘twisted’ face if one is looking from above. This is apparent by misaligned ears (the ear on the affected side may be pulled forward and down and be larger then the unaffected ear) and facial asymmetry, with the more forward side of the face having a fuller forehead, brow bone, and cheek. The jawbone will be tilted and one’s occlusion (bite) may have a cant to it. There may be differences in the position and shape of the jaw angles and the chin may be deviated toward the ‘weaker’ or more retrusive side.

When the facial asymmetry is very severe, complete facial bone repositioning incorporating orthodontics and multiple jaw orthognathic surgery is needed. But most of such facial asymmetry that I see in my Indianapolis plastic surgery practice is more mild and in late adolescence or adulthood. Patients are looking for less major methods for improving their facial asymmetry.

When one considers improving facial asymmetry, a careful analysis of the face must be done to determine exactly where the imbalances are. Of even greater importance is input from the patient as to which facial prominences they consider to be the good or the bad side. This is very important because weak areas can be built up with implants which is most commonly done because it is easier. But reduction of bone can be done in certain facial areas if they are too prominent.

Options in facial asymmetry correction include from top to bottom: forehead/brow augmentation, forehead/brow reduction, cheek and orbital implants, jaw angle augmentation or reduction, inferior border mandibular ostectomies, and chin osteotomies or implants. Such an array of procedures requires thoughtful and careful preoperative planning. When more than one of these is done during the operation (which is most common), the effects of facial rebalancing can be quite significant. In my experience, at least two or three facial areas are treated at the same time to get the best result.

 While complete or perfect facial symmetry is not obtainable in any case, significant camouflaging of the facial bony asymmetries can be made. Such surgical improvement provides great psychological relief to the facial asymmetry patient and can usually be achieved in a single operation.   

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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