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Background: Plagiocephaly is a well known aesthetic head shape deformity in which the origin of the name means twisted skull. When viewed from above the skull shape is also often called cranioscoliosis based on its axis of rotation. in the majority of cases this rotation is counter clockwise, meaning the right back of the head is flat and the left forehead is flat. The reasons why this counterclockwise rotation is seen more frequently than a clockwise rotation is not known. But regardless of the rotation axis the back of the head usually has a far greater flattening than on the front of the head.

In adult plagiocephaly many more men present for aesthetic improvement than females. This is undoubtably because the male head shape is much more exposed than that of women due to less hair coverage. While 100% of the patients who appear for plagiocephaly correction are concerned about the back of the head flattening a much smaller percentage have forehead shape concerns. This is either because their forehead is not affected at all or that the flattening effect is very mild.

When there is a visible forehead flattening present such patients may desire to treat both the front and back of the head. This can be down with custom designed implants. The only question is whether the patient wants to treat both skull areas at the same time or separately.

Case Study: This male has congenital plagiocephaly which affected both the front and back of his head which he wanted to correct at the same time. Using his 3D CT scan a larger right back of the head implant and a smaller left forehead implant were designed.

Interestingly and very common is that he saw his skull shape issues in the oblique views as the primary aesthetic problem, making the back of his head and forehead look ‘cut off’ from these angles. Thus the implants designs can be thought of as corner augmentation of the flatter angles of the skull.

In doing total plagiocephaly correction the back of the head implant is done first. Through a small posterior scalp incision the right back of the head implant is placed and secured with double screw fixation.

The left forehead implant was placed through a very small frontal hairline incision and similarly secured with double screw fixation.

For those patients who have significant flattened unilateral back and front of the head, a dual custom skull implant approach can be used for a complete plagiocephaly correction. The term ‘complete’ must be accurately defined since some aspects of plagiocphaly can never be completely addressed. But for the skull shape deformities of it the custom implant is as complete a correction as is possible. This is usually possible in a single surgery of the combined implant volumes stay under 150ccs. In this case the two skull implants had a combined volume of 70ccs which is well within the tolerance of the scalp to stretch to accommodate them.

Case Highlights:

1) While the most common effect of plagiocephaly is a flat back of the head on one side, the opposite side of the forehead can also be affected.

2) In a more complete correction of plagiocephaly in adults combined forehead and back of head implants are used to correct the flattened areas.

3) Both forehead and back of head skull implants can be placed through small incisions that do not carry much aesthetic liability.

Dr. Barry Eppley

World Renowned Plastic Surgeon

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