Can An Occipital (Back of the Head) Implant Augmentation Be Revised For More Projection?
Q: Dr. Eppley, I wanted to thank you for the kind and professional treatment by you and your staff during my stay in Indianapolis for my occipital augmentation surgery. My scar on the back of my head is healing nicely! I almost can’t see it when I use a mirror to see the back of my head. Overall, in terms of the shape of the back of my head, I’d say there’s a 60% to 70 per cent improvement. However, as you correctly noted during our visit the day after my surgery, my head is/was really flat in certain areas, and the implant may have not been created with sufficient thickness/volume to create a “rounder” effect. It’s funny, with the CT scan, I’d have thought the outer implant shape would be super-precise. So I am wondering about the possibility of doing a revision. I am grateful for the improvement so far, but I sometimes think that the back could be a bit “rounder”, and hence, I start pondering my options. Do you think it would be worth doing a revision for more occipital projection?
First, the computer design process did a very precise job of making the implant perfectly. What the computer can do is to make it fit the bone perfectly, make the implant symmetric based on differences of the shape of the underlying bone and make its outer surface and edging as smooth as possible. That is has done wonderfully. What the computer can not do is to inherently know what the shape and thickness of the implant should be based on aesthetic goals. That is the role that I play and it will only follow the design that I instruct it to do. My job is to design an implant that will fit given the tolerances of the overlying scalp and be able to be placed through the smallest incision possible. Occipital implants that are too big can cause catastrophic problems, such as scalp and incisional tissue necrosis, hair fall out, non healing wounds, infection and the need to do a lot of ‘wittling’ on the implant trying to make it fit. (resulting in irregularities and asymmetries) It is my experience and judgment that allows for these type of problems to be avoided. That is why your implant, like many patients, is not designed to be thicker than 9 to 10mms as this is what I have learned to be a safe implant thickness that will always avoid any of these concerns. Most of the time patients will say down the road that they wish it was a little fuller after they get past the initial euphoria of having some augmentation effect. But it is always better to have a 70% result that has never experienced any complications vs. having the perfect volumetric result that has developed a complication.
When it comes to a ‘revision’, this is often a poor term to use and the incorrect way to think about it. Understandably patients think that ‘just adding a little more’ or ‘making an adjustment secondarily’ is easier than the first time. But the reality is that it is exactly the opposite. It is now harder because the tissue are more scarred and the scalp is less flexible. You may be able to place an implant that is 4 to 5mm thicker but it will likely require a bigger incision, a whole new implant, and will increase the potential for any of the complications that I have previously described. (the risk may be still fairly low but it is higher than the first time). Thus one has to weigh the risk vs. benefit for that extra 20% to 30% gain of improvement that could be achieved.
While I am happy to place a whole new implant, and I have done it many times for patients with many different kinds of skull and facial structural surgeries, it is important to understand that every surgery has risks. Just because it worked perfectly the first time is not a guarantee that it will be so the next time. Manipulating otherwise uncomplicated aesthetic results should be considered carefully if not more so than the first time.
Dr. Barry Eppley