Q: Dr. Eppley, Our four year old daughter has a flat back of the head due to positional brachycephaly. She has the additional bone growth over her ears that we would consider also having reduced. We want to know our options for building up the flat spot when she gets older. What is the right age? Have you built up flat spots for younger kids? We’d prefer to wait until she’s at least a teen but want to fully understand our options. Does the single step procedure provide enough material to build up the flat spot to the satisfaction of most clients or would you anticipate the two step method where the scalp is stretched to accommodate more material might make more sense?
A: The timing of elective skull augmentation for a flat back of head is matter of personal preference. In my opinion, it can be done very young or anytime later in life. Building up the bone requires the overlying scalp to stretch and age does make any difference in that regard. Since this is an onlay technique, the hydroxyapatite cement will grow with the surrounding bone so age is not a concern in that regard. I have done a child with unilateral occipital augmentation as young as age 4. The timing is merely a matter of parental and, if old enough, patient choice.
Because your child has bilateral occipital issues with biparietal width increase, the need to reduce the wider bone indicates a need to do it when she is older and the bone is thicker. So the teenage years would be a good consideration in your child’s case. While most cases are done in a single stage procedure, that would depend on how flat it is and how much occipital expansion is needed. If more than 15 to 20mms of occipital expansion is needed, then a first stage tissue expansion would be needed.
Dr. Barry Eppley