Top Articles

Background: The back of the head has the greatest diversity of shape abnormalities, most commonly flat areas. The two most common types are asymmetric flattening due to plagiocephaly and bilateral flattening due to external deformational forces. There does not appear to be too much difference between them in occurrence based on patients that have presented for treatment.

The flat back of the head can have several difference presentations based on where the lack of projection exists. In a completely horizontal flatness the occipital bone is the primary deficiency bone and the parietal bones above it are less flat. In the obliquely flat back of the head the parietal bones are the primary culprit and the occipital bone less so. In less common and in the most severe flattening cases both the occipital bone and the parietal bones are equally flat. 

Case Study: This young male had long been bothered by his flat back of his head but his concerns were magnified after four years in the military. (where he had a short haircut) His 3D CT scan showed an obliquely angled back of his head with a pseudo prominent niche ridge at the visible end of the occipital bone. There was some increased flatness on the right compared to the left.

Using his 3D CT scan a custom  back of the head skill implant was designed with an angulated point of maximum projection of 15mms. Total implant volume was 123ccs.

In the angulated flat back of the head deformity the point of maximum projection is higher than in the straight or flat back of head deformity.

Under general anesthesia and in the ;prone position a zigzag 7cm long scalp incision was made over the nuchal ridge. Subperiosteal dissection was widely done and the key landmark identified to aid in implant placement…the midline notch above the projecting nuchal ridge.

The custom skull implant was passed through the incision, positioned in the midline using the nuchal notch and secured with a single micro screw. A two layer closure was done over a drain.

When seen the next day for head dressing and drain removal the impriovement in the shape of his back of head was readily apparent and very satisfying for him.

The flat back of the head is a common and distressing skull deformity for those affected. Using a custom skull implant design and a 90 minute surgery this lifelong head shape concern can be dramatically improved with a short recovery period.

Case Highlights:

1) Significant back of the head deficiencies are a combination of lack of occipital and biparietal bone projections.

2) If the nuchal ridge has adequate development it serves as the placement insertion for a custom back of head skull implant.

3)  An implant for the flat back of the head represents a 90 minute surgery to correct a lifelong head shape concern.

Dr. Barry Eppley

World-Renowned Plastic Surgeon

Top Articles