Q: Dr. Eppley, I have a flat head from behind. It has been that way since my childhood since I always slept on my back and never changed positions. I came across your procedure while looking for ‘flat head treatment’ on the Internet. I have a few questions.
- I wish to know how much improvement I can expect with the treatment. Can I get a completely round head?
- I also wish to know how exactly it feels after the implant is placed under the scalp. When I touch the back of my head would I feel like there’s something there or would it feel like bone?
- About the material, can it be carcinogenic or can it possibly cause any allergic reactions?
- Would the material completely adhere to my skull and not float around between the scalp and the skull?
- Can the procedure be done under local anesthesia?
Thank you in advance for your reply.
A: In answer to your questions about flat head correction using a custom implant:
- Only with a two-stage (first stage scalp expansion) can you get a fairly round head. one-stage occipital implant on the back of the head will produce about of that ideal result.
- The implant will feel like bone.
- A silicone implant os not carcinogenic nor will it cause any allergic reactions.
- The implant will not float around and will adhere to the underlying bone and the overlying scalp.
- The procedure can NOT be done be done under local anesthesia, it requires a general anesthetic.
Dr. Barry Eppley
Q: Dr. Eppley, I have a flatness in the occipital area of my head which is very pronounced, especially with short or wet hair. I have x-rays with a little outline of the augmentation I wish to accomplish. If I were to proceed with an augmentation procedure I would prefer a custom occipital implant. With today’s technology, how big of an incision should I look forward to, and where would this incision be made? Can a custom occipita implant be fabricated using the x-rays I have or is there another form of imaging technology that needs to be used? There is also a slight bump on the top left side of my head. If I wanted to try an shave that down a bit, how much would the incision size change, and can that same incision be used to insert a custom implant for the occipital portion?
A: A custom occipital implant is made from a 3D CT scan, no other form of x-ray will suffice due to inadequate imaging data. A custom occipital implant is usually placed through a low horizontal scalp incision on the back of the head. Unless the skull bump is very near the location of this incision, it would not be able to be reduced through it and another scalp incision closer to it would be needed. There is also the alternative of making a higher scalp incision where the custom occipital implant could be placed and the skull bump could be reduced through the same incisional access.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a custom skull implant.I have a flat back of the head, that I hide every day as much as I can with my hair (no hair loss). I am interested in the skull reshaping procedures using custom implants described in the page: http://eppleyplasticsurgery.com//skull-reshaping/. I am particularly interested by the computer designed flexible implants, and the example photographies of a skull with/without implant in the middle of the section ‘custom skull implant’ matches quite closely my situation. I believe that an additional 50cm3 volume would be largely sufficient to get the desire ’rounding’ effect, after testing with plasticine, however I do not know if this volume would fit under my scalp.
I have listed below my questions (I have a lot, but I am considering very seriously this surgery), I hope you can answer them either by mail or a scheduled interview, as you see fit (however I’m more comfortable writing english than speaking it):
1) what is the volume range of the implants that can be inserted?
2) what is the material used to 3d-print the implant? How long is it supposed to last?
3) what would be the size and position of the scar necessary to insert the implant?
4) can you give me the necessary details of the 3D imagery you need, so that I can already schedule the skull scanner in a nearby laboratory?
5) what would be the cost of such an intervention?
6) If the implant has to be removed, even a few years later. Iis the removal a simple process? Can the screws be removed?
Thank you for your time.
A: In answer to your questions about a custom occipital implant:
- I do think of skull implants in terms of volume. Rather I think about their maximal thickness and how the scalp can stretch to accomodate it. In general, a custom occipital implant of 10 to 12 mms thickness can be tolerated by most patients regardless of the surface area that it covers.
- The implants are made of solid silicone and will last forever.
- The implant is inserted through a low horizontal scalp incision on the back of the head.
- A high resolution (.1mm thocknes slices) skull 3D CT scan is needed.
- My assistant will pass along the cost of the surgery to you tomorrow.
- The implant can be easily removed later. I no longer use screws for implant fixation as they are not needed.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a custom occipital implant. My head is obviously flat. I have been insecure about it since my teenage years. I am know in my late 20’s. I am interested in a custom occipital implant to make the back of my flat flat head perkier and rounder. I was wondering what the estimation of this procedure would be? I was also wondering, since you cut the hair/skin part of the back head, is the scar obvious (aside from hair covering it)? For example, if I were to show that area would the scar be obvious? Thank you. I look forward to your reply.
A: For augmentation of a flat back of the head, a custom occipital implant is the best method. It does require a scalp incision somewhere and that would depend on its size and location on the occiput. The scalp scar usually turns out very well particularly in women. If you shave your head the scar would be somewhat obvious but that is the situation you probably are not going to find yourself in. Great care is taken in aesthetic skull reshaping surgery to preserve hair follicles along and around the scalp incision.
Dr. Barry Eppley
Q: Dr. Eppley, I have a very flat back of my head. I’ve never had any problems but as a female I can only wear my hair down and I puff it up everyday so you can’t see it. But by me doing that it is causing hair loss around that area. It is honestly very embarrassing and I am very insecure about it. Also my forehead is flat and the way my nose is shaped does not help at all. So I’m talking maybe three surgeries but I’m not sure how that all works. I have attached a series of pictures so you can see the scope of my concerns. Please reply I would amazingly appreciate it.
A: Thank you for sending your pictures. It is a very classic and common type of occipital-vertex deficiency that I see in women. While it can be very effectively augmented by a custom made implant (custom occipital implant) the question is how much augmentation do you seek…which defines whether it can be done as a single stage or requires a first stage scalp expansion by a tissue expander. Essentially a first stage can augmented the entire area by about 12 to 15mms maximum. A two-stage approach can augment the skull by 25 to 30mms. This is an important consideration up front. Ultimately the question is whether one wants a modest augmentation (one-stage) or a more significant one (two-stage) when it comes to designing a custom occipital implant.
Dr. Barry Eppley
Q: Dr. Eppley, I had a custom occipital implant three months ago. While I was initially thrilled with the results, I now feel that I wish it was bigger. Do you think it is too soon to consider a revision? Also my scalp is still somewhat numb, less numb than right after surgery, but somewhat still numb. Is this normal?
A: First, it really takes a good six months to have all normal feelings return to the scalp and to really ‘forget’ that one has a custom occipital implant on top of their head. It also takes one about the same amount of time to psychologically adjust to an extended body part and to put it in perspective. Thus you really are not there yet and what one feels today may or may not change later. So in the interim the following comments may be helpful to gain some further perspective.
It is extremely common, and almost expected, that every occipital implant augmentation patient eventually feels that they could have used more of an augmentation or some change in the augmentation location. They may feel that maybe the implant should have been designed bigger or placed differently or may even consider having a second implant done. This is known in the plastic surgery world as another ‘spin at the roulette table’ or ‘another bite of the apple’ to use a few common American phrases. I sum it up more psychologically as ‘cosmetic accommodation’.
This is common in this type of surgery because the reality is that a one stage approach can usually only achieve about 60% to 70% of the ideal augmentation one wants due to the limits of the scalp’s ability to stretch. The most ideal results always come from a two stage approach with a much larger implant. This is a discussion to have up front as one has to choose between the more efficient one stage approach that produces less than one ultimately probably wants or a more costly two stage approach for the ideal result. Besides the initial expansion phase, a two-stage also requires a change in the incision to across the top of the head rather than low in the occipital hairline.
Your preoperative situation with an already existing occipital scar throws a variable into the occipital augmentation planning….as it becomes the only way to place an implant as any incision across the top of the head places the stretched and/or expanded skin between the two incisions at risk for skin or hair loss. You always only had the option of the use of your existing occipital scar whether you had tissue expansion or not.
From the occipital scar location, it would have never been possible to get an implant any further forward than where it is right now. You simply can’t get around the curve of the skull to make a pocket from an incision that low in the hairline. You should take some solace in that you have had the maximum thickness of implant placed as far forward as was possible given the constraints of the incisional access. (15mm height)
In a few cases I have had occipital implant patients who really want to go for a second implant to get an even greater result. Without tissue expansion this is usually not possible. But even it were I would caution any implant patient to resist the temptation to take an initial uncomplicated surgical result that is good, but perhaps not perfect, and try to make it better. The next time around they may not be so fortunate.
Hopefully these comments will provide some additional perspective on your recovery process and the final result as you eventually gain full perspective on it.
Dr. Barry Eppley
Can Head Width Reduction, Cheek Bone Reduction and A Custom Occipital Implant Be Done During The Same Surgery?
Q: Dr. Eppley, I am interested in getting head width reduction surgery, cheekbone reduction surgery as well as surgery to augment the back of my head. The first photo I attached is in regard to head width reduction and cheekbone reduction surgery. From the info on your website, I see you do removal of the muscle after the yellow line in my photo. I am curious to know if you can do removal of muscle after the red line in my photo. Also, I will always have very short hair on the side, since it make my head looks smaller. How visible will the scar be after the width reduction with my short hair?
I had a cheekbone reduction before but my surgeon didn’t reduce any more cheekbone after the first blue line in my photo due to concern of nerve damage. Since most of the width of my face is in between the two blue lines. The cheekbone reduction i had is largely ineffective in making my face more symmetrical and narrower. I was wondering if you are able to reduce the cheekbone between the two blue lines where my previous surgeon was concerned with nerve damage
Lastly is in regard to the augmentation of back of my head, my current head shape is similar to the baby in the second pictures. I am curious in getting a custom implant to make my head look more normal.I consulted with a craniofacial he advised me against a custom implant because of high risk of infection. How high is the infection rate of these implants, and How much will total cost of this specific surgery be including getting a 3d CT scan, a custom implant made, and all the other fees including surgeon fee?
A: When it comes to temporal muscle reduction, the actual line of reduction is from the top of the ear angling upwards to just behind the temporal hairline along the forehead, so it is in front of the red line that you have drawn. Most of the incision is behind the ear and it is done largely endoscopically above it.
The cheek bone a you are illustrating is the tail end of the zygomatic arch where it attaches to the temporal bone. If this part of the cheek bone is not fractured inward with the front part, little change in cheek bone width will result. An osteotomy is done in that area through a small incision at the junction of the beard skin and non-hairing skin. The temporal branch of the facial nerve runs in front of this incision so there is no risk of nerve injury. This is actually a standard approach to cheek bone reduction osteotomies as both the front and back ends needs to be cut and moved inward.
I have done many custom occipital skull implants as well as many other implants for other skull augmentation areas. I have yet to see an infection so the claim that they are prone to a high rate of infection has not been my experience.
Dr. Barry Eppley
Q: Dr. Eppley, we have talked before and i was trying to get surgery done for flat back of the head in 2011. I had some financial problems that is why I didn’t do it. Back in thoe days we talked about Kryptonite bone cement method which it had minimum scarring but expensive. I’m looking in to doing the procedure sometime this coming October 2015 and I was browsing your websites and I found this new approach that you have called Custom Skull Implants by using 3D CT scan.
My questions are
1- What is the price difference between Krypton bone cement and custom skull implant
2- I know the scar is less in Krypton bone, but how big is the scar for implant
3- Recovery time for the implant?
4- How long it will take to make the implant after CT scan?
5- Infection risks?
Thank you very much
- My assistant will pass along the exact cost of a custom occipital implant to you tomorrow.
- The incision is usually placed very low in the occipital hairline and is usually a horizontal incision of 7 to 9cms. When the incision this low, almost in the upper neck, any scar concerns are significantly diminished.
- Recovery is usually less than a week to return to most normal activities.
- It takes about 3 weeks to design and manufacture the implant after the 3D Ct scan is received.
- While infection is always a concern for any implant in the body, I have yet to see one with a custom silicone occipital implant.
Dr. Barry Eppley
Q: Dr. Eppley, my son of 10 years of age has occipital plagiocephaly and a big flat spot in the back of his head. I recently sent in his old CT scan and updated photos to a doctor in our area. The surgeon recommended waiting for the completion of puberty and then to evaluate for an implant in the back.
This doctor did not not recommend a silicone implant. If I recall correctly, he said they were found to deteriorate with time. Do you know anything about this? Do you still think a silicone implant is okay for the skull? Things seems to change with time and between surgeons.
The thing I like about silicone implants is the reduced incision length. The doctor thought imaging could be used to determine the optimal location and length for an implant made of some material other than silicone. What are your thoughts on this?
A: I do agree that waiting until after puberty to have the occipital implant surgery is reasonable. However, it is absolutely not true that silicone skull implants degrade with time. They can never breakdown or degrade. Silicone is a fundamental element (#14 on the Periodic Table) and there are no human enzymes that can degrade the material. A thousand years from now the implant will look the same as the day it was put in.
There are a variety of materials that can be used for a custom occipital implant including silicone, HTR and PEEK materials. While these materials are chemically and structurally different, how the body reacts to them and treats them is not fundamentally different. The biggest difference to a patient is going to be the length of the incision to place them. Stiff rigid materials like HTR and PEEK are going to require a full coronal incision to place. Conversely, silicone can be placed through a much smaller incision because the material is flexible.
Dr. Barry Eppley