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Dr. Barry Eppley

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Posts Tagged ‘skull augmentation’

Skull Augmentation in Young Children with Plagiocephaly

Thursday, November 12th, 2015

plagioccephalyPlagiocephaly is a term used for a broad collection of congenital skull deformities that involve a general twisting or rotation of the skull base. This is most commonly seen as flattening on one side of the back of the head with compensatory changes anteriorly to the forehead and face. When diagnosed early skull molding therapies with helmets can be very effective in lessening the head shape deformity. But if not treated within the first year of life, the success of cranial molding therapy decreases significantly.

Unlike more severe skull deformities like craniosynostosis, plagicephaly is not generally viewed as severe enough in many cases to warrant major intracranial surgery through bone removal and reshaping. Flat areas on the back of the head are viewed as ‘cosmetic’ with no medical indication for surgical intervention…as viewed from the typical craniofacial surgical perspective. Certainly it is hard if not impossible to justify a major operation with a long scalp scar and need for blood trasnfusions to correct a mild to moderate occipital skull shape problem in a young child.

It is common in my practice to correct a wide variety of skull shape issues in adult with ‘aesthetic craniofacial’ techniques. This essentially means two fundamental approaches that differ from traditional craniofacial surgery methods…a very limited scalp scar and correction of the deficient skull with onlay bone cement methods. This requires experience in working with a variety of alloplastic cranioplasty materials and doing so with limited incisional access. This has proven to be a very effective approach with good skull contour improvements.

hydroxyapatite cement skull contouring dr barry eppley indianapolisThere is no reason that such a limited incisional skull contouring procedure can not be safely and effectively applied to young children with plagiocephaly skull concerns. The key component to this approach is the type of contouring material (bone cement) that is used. A bone cement material like hydroxypatite cement, while synthetic, has a highly osteoconductive surface and allows bone to bond directly to it. (does not develop a scar interface like a truly synthetic material would) While never being resorbed and replaced by actual bone, it is extremely well tolerated and will allow any remaining skull growth to be unimpeded. (At three to four years of age, the skull has undergone over 70% of eventual skull size anyway) Thus the skull contouring effect achieved will be maintained as the child continues to grow.

Having done a small series of hydroxyapatite cement skull augmentations in children (under age 5) for flat spots on the back of the head, it is an effective procedure with a very quick recovery. Most scalp incisions have been less than 5 to 6 cms in length. It is a challenge to work with bone cements through such a small opening but years of experience with the material have helped tremendously.  For the very motivated parent(s), treatment of mild to moderate plagiocephaly can be vey safely done at a young age.

Dr. Barry Eppley

Indianapolis, Indiana

Small Sagittal Skull Implants

Sunday, April 26th, 2015


While the skull is often envisioned as a perfectly smooth oval shape, it often isn’t. Due to how the cranial sutures fuse and intervening bones form, the surface of the skull is often irregular. Such irregularities often occur along the suture lines due to their early activity during development and closure right after birth. They are frequent sites of  high spots, bumps and dips and indentations.

The sagittal suture is the longest of the cranial sutures due to its midline longitudinal course from the upper forehead to the top of the back of the head. Its midline position gives it a visible form in both the front and profile views. Any abnormalities along the fused suture line is most easily seen in the short haired or shaved headed male. One such sagittal deformity is a dip that appears between the front and back portions of the sagittal suture line. This is usually due to higher bone formation that occurs around the areas of the former front and back soft spots (fontanelles) as they initially fused together.

Sagittal Skull Implant Dr Barry Eppley IndianapolisCorrection of this sagittal skull dip can be done by filling in between the raised front and back skull areas. This can be done by using a linear shaped skull implant that sits in the dip. Such a small and unusually shaped skull implant can be made from various materials including silicone elastomer. They can be designed from measurements, an elastomer moulage or even from a 3D CT scan of the patient.

sagittal skull implant indianapolis indianaThis small linear implant can be placed under local or IV sedation through a small 2.5 cm scalp incision. It is inserted after making a very precise midline pocket that does not extend beyond the length of the implant. Small perfusion holes are placed in the implant to allow for tissue ingrowth and long-term stabilization.

Skull augmentation can be done for a diverse group of skull defects even those as small as the sagittal dip.

Dr. Barry Eppley

Indianapolis, Indiana

PMMA as an Aesthetic Cranioplasty Material

Sunday, June 9th, 2013


The use of skull reshaping with cranioplasty techniques that use synthetic materials dates back for over five decades. While the use of bone grafts is never an option in aesthetic skull procedures, it often is not an option in skull reconstruction either due to the size of the skull defect. This makes the use of alloplastic materials, often called bone substitutes or bone cements, as inevitable for many skull restoration procedures.

One of the historic and still most commonly used alloplastic bone substitutes in the skull is poly methylmethacrylate. (PMMA) Even though it is a polymer-based material and will never permit bone ingrowth or bone replacement, its low cost for its large volumes have always made it popular. Its widespread spread in joint replacements in orthopedic surgery as a true bone cement also speaks to its excellent biocompatibility.

Skull reshaping using PMMA has long shown it to be a well tolerated implanted material.   A recent published paper in the June 2013 issue of Aesthetic Plastic Surgery entitled ‘Aesthetic Refinement of Secondary Cranioplasty Using Methyl Methacrylate Bone Cements’ is interesting as it provides a more recent patient experience. Over a three year period the authors report on 20 patients who had PMMA implanted in their skull. Their use was reconstructive in nature for trauma and craniotomy patients and was used as a total inlay in the majority of the patients. (85%) The size of the cranioplasties was from 30 to 144 cm2 in size and involved implanted material volumes of 20 to 70 grams.

After an average two year followup period, no patients showed any evidence of implant infection, exposure, or extrusion. In addition, the PMMA reconstructions were structurally stable over this time period all the patients. The key to such successful outcomes in their observation were adequate and healthy overlying scalp tissues.

What does this mean to the aesthetic skull reshaping patients who has or is considering having PMMA implanted? This study is a small patient series that does not have significant long-term follow-up and used the material in an inlay rather than an onlay fashion. On the surface it would seem that this patient series has little correlation to aesthetic skull augmentations. But it does in one important way other than using PMMA…the scalp. All patients had overlying scalps that were healthy, not irradiated or missing tissue. Thus when re-expanded outward at the time of the reconstruction they developed no wound breakdowns or exposure.

PMMA is an effective and safe cranioplasty material. I have implanted far more PMMA in aesthetic patients than is in this paper for reconstructive purposes. I have been impressed with how well PMMA performs even though it is not remotely similar to its distant cousin, the hydroxyapatite bone cements. It does particularly well in the aesthetic skull augmentation patient undoubtably because the scalps are healthy and have never had surgery. Successful skull augmentation outcomes are predicated on normal scalp tissues because they will be stretched as the skull is built up underneath it.

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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