Your Questions
Your Questions
Q: Dr. Eppley, As for back of the head surgery (occipital augmentation) I have a few questions?
1) how much in cm or mm can I expect the head to become rounder using implants?
2) if the implants get infected how dangerous is it? Can it be prevented or treated?
3) Very important question – So the back of my head is flat but it is not level. The right hand side it is about 1 cm bigger than the left so basically I have Plagiocephaly and brachephly. (I think) Can a good result still be achieved and how? Are you able to shave some bone off the skull to get it to the same level and then insert the implant?
A: Thank you for your inquiry. In answer to your questions about occipital augmentation by an occipital implant:
1) Usually 12 to 15mm is the maximum implant thickness that most scalps will accommodate.
2) I have never seen an occipital augmentation infection. But the implant can be easily removed if needed.
3) With skull asymmetry the implant would only be placed on some side to have the two sides match. In these cases, the best way to make the implant would be from a 3D CT scan to get the best match between the two sides.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am hoping you can give me your professional opinion about my problem. I have been bothered by a fairly flat back of my head for decades now and I am at that point that I really want something done about it. Some stories sounds promising which make me hopeful but I am not even sure I am a ‘suitable’ client. What do you think as far as you can tell from a picture? How long will the procedure take (from intake to recovery) as I need to travel to the States. Thanks for your time.
A: When it comes to determining a good candidate for back of the head augmentation (occipital augmentation), pictures can go a long way in answering that question. Please send some to me at your convenience. The issue is not likely going to be whether you can have the procedure done but whether it is a one-stage vs a two-stage procedure based on your back of head shape goals and your natural scalp laxity to accommodate that change.
Back of the head or occipital augmentation is usually best done by a custom implant made from a 3D CT scan. Although I have done enough of these surgeries to have a ‘stock’ set of implanted designs from prior patients that can be used which does not require a preoperative 3D CT scan. Either way it takes about 3 weeks to have the implant made and ready for surgery.
Patients from other states or countries usually return home within 48 to 72 hours after occipital augmentation surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in occipital augmentation surgery. My 5 year old son has a flat spot on the back of his head. We consulted out pediatrician about it from an early age and were told it would “round out”. It didn’t so at 18 months we paid out of pocket for a helmet and got minimal results because of he was passed the age of best results.
This has caused a lot of pain and regret for us even though my son doesn’t have a clue that anything is wrong. At what age is it safe to consider doing something about the issue? We don’t want him to face any social issues because of bad advice from our pediatrician and late action on our part. What are our options?
A: The aesthetic correction of unilateral occipital plagiocephaly by occipital augmentation can really be done at just about any age in my opinion. Correction involves building out the bone with hydroxyapatite bone cement (at at early age) or a custom made implant at older ages. Whatever is placed on the bone will grow with the slowly expanding skull growth. I think hydroxyapatite cement is most appropriate for young children since its the inorganic mineral content is most similar to bone. The decision and timing for occipital augmentation surgery at this point in your son is a personal one and is most appropriately done when you and your wide deem it most psychologically protective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interesting in a skull reshaping procedure for a flat side to the back of my head. In my pictures you can see the difference between the two sides of the back of my head. I want to see if you could make the smaller side of my head (left side) look the same as the bigger side (right side). My ear on the flatter side also sticks out nore. Even though it would cause me to have a large looking skull I wish to find a sense of normalness.
A: Thank you for sending your pictures. You have a classic case of plagiocephaly with left occipital flattening and contralateral right frontal flattening. (cranioscoliosis) The skull reshaping treatment for it is an occipital augmentation on the flatter side. The protrusive ear can be set back in a more traditional setback otoplasty with conchs-mastoid sutures. I assume when you mean ‘make the smaller left side of my head look the same as the bigger right side’ you are referring to using a standard/semi-custom implant or bone cement to do so. I think I would use one of my preformed occipital implants that I use for plagiocephaly cases. It is not as perfect as a truly made custom implant from a 3D CT scan but it can make for a major improvement and lowers the cost of this skull reshaping surgery somewhat.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
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?
A: Let me provide with some insight as it it relates to a result that has ‘60% to 70% improvement and what a ‘revision’ really means.
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
Indianapolis, Indiana
Q: Dr. Eppley, Please help me I have flat head from the back and it looks ridiculous and people are laughing at me . And I’ve been suffering for over 22 years. I want to ask do you you have plastic surgery for the back of my head and please tell me the solution. I have attached a picture for you to see how bad it is.
A: Thank you for sending your picture. I will admit, and I have seen many flat back of the heads, that you do have an impressive one. It is one of the flattest back of the heads that I have ever seen. There is no question there is improvement to be had with flat back of head surgery, it is just a question of how much and what effort do you want to put into it. There are two basic approaches, either a single stage or a two stage approach. In a single stage approach, a custom implant or PMMA bone cement is use to create a moderate improvement. In a two-stage approach, a first-stage tissue expander is placed to stretch out the soft tissues. Then a custom implant or bone cement is placed to get a more significant change. (at least double that of the one-stage) Either way, you definitely can get a positive improvement from the very flat back of the head that you have with these occipital augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have done some research on an occipital augmentation cranioplasty for a flat back of the head. I am still about 18 months away from having the money to receive such an operation but in the meantime I have two questions.
1.) What are the long term effects of such a operation?
2) How long is the scalp incision to do the surgery?
3) If I sent in a picture, is there any way to get a good estimate of the size of the needed incision? And is there a way to see what possible results would look like on myself?
Thank you for your time!
A: In answer to your questions:
1) Based on my extensive occipital augmentation experience, I have yet to seen any long-term untoward consequences such as implant problems (infection), skull or scalp issues. There can be some aesthetic issues such as smoothness and edge transition blending into the bone.
2) The size of the incision is going to be based on what implant method is used, preformed implant (6 to 7 cms) or PMMA bone cement. (9 to 10cm) That is predictable up front.
3) Side view pictures can be used to show potential result predictions using computer imaging techniques.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in occipital augmentation. I have a flattened head at the back which is also assymetrical. It has been a major problem for me for many years. Isolation and depression are the main effects. I have a local surgeon who is tells me a PEEK onlay is the best option. Would you consider this to be better than a filler material. He tells me I will have a transcranial scar and will have to have my hair cut short, preferably shaved. The argument for the onlay is it is difficult to achieve a smooth transition with filler material. I should add he has never done this operation before. Could you give me any advice. I am a little nervous about head shave and a huge incision.
A: After having performed over 100 occipital augmentations with every known material (except PEEK) and method, I can tell you for certain I would never use a hard preformed material like PEEK. (or preformed HTR or preformed acrylic for that matter) The material on insertion is too hard and this requires a maximal incision to get it into place. That may be fine but I don’t know of too many patients that want a full coronal incision for their occipital augmentation.
The two most commonly used and preferred cranioplasty materials in my practice are either intraoperatively fashioned PMMA bone cement or a preformed silicone implant. Either of these materials can be placed with much smaller incisions and work well. I have not seen an infection with either cranial augmentation material to date. This does not mean these methods are perfect (PMMA can have some edge transition issues because of its intraoperative fashioning) but these issues are aesthetic and not of any major medical significance.
FYI, I do not have my patients shave any hair for their skull augmentation regardless of the material or approach.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have few question regarding forehead augmentation and back of the head augmentation. I would appreciate your kind answers to each of them one by one.
1. Which procedure is more durable, bone cement or implant?
2. Can you please tell the advantages and disadvantages of each?
3. Is it possible that bone cement is filled without cutting the scalp, so we fill the scalp by injection three to four time(interval of ten days) and it may increase the whole head size?Because i fear of cutting scalp and tissue expander.
4. Is bone cement strong enough like skull bone?
5. Which procedure do you recommend?
A: For forehead and occipital (back of the head) augmentation, there are two basic materials that be used…bone cement and preformed implants. In answer to your questions:
- Both material are equally durable. Neither can degrade, be broken down or will ever need to be replaced because they ‘wear out’.
- Each material type has its own unique advantages and disadvantages. Bone cements must be mixed, applied and shaped during surgery thus taking more operative time to do. Preformed implants are made before surgery off of a 3-D CT scan of the patient’s skull. By computer design they provide the best and most symmetrical augmentation with the least risk of any irregularities at the implant-bone transition areas. They can also be done with less operative time. From a cost standpoint, they are roughly equal.
- With either approach, a scalp incision is needed. There is not injectable cranioplasty technique for this size of skull augmentation areas. There is no need for a tissue expander with your dual augmentation.
- The resistance to fracture is roughly equal between PMMA bone cements and skull bone.
- I find both procedures can make for successful skull augmentations. The choice between the two is a matter of personal preference and which one sounds better for each patient. Both type of forehead and skull implants can be done very successfully.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping surgery. My head shape is not normal. It is flat from the back side and inclined backward at the forehead making it smaller on the top as a whole. My face is not much wider as well resulting in a small head. I want to increase head size especially from my back side and forehead areas. Please tell me which procedure I need whether it is an implant or bone cement filling.
A: When it comes to skull reshaping and the aesthetics of your skull, you are talking about a sagittal (front to back) deficiency. Your forehead is slanted backward (retroclined) and the back of the head is flat. (or has a reverse retroclination compared to the front. This is treated by two different methods of dual forehead and occipital augmentation. It can be done with either a bone cement filling material (usually takes 150 grams) or custom forehead and occipital implants made from 3D CT scan. There are advantages and disadvantages of either approach but the end results of either one are the same with a potentially dramatic difference in the volume of your skull from front to back.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been looking into cranial augmentation and it has led me to here. You seem to have a lot of experience in the matter so I have a few questions. I have flatness in the back of my head and also a hump on the top of my head. If you look at my pictures, the flatness starts at point A up to the top of my head. The hump starts at point B and continues to point C. I have also outlined a drawing of how I would like the final result to shape into. My questions are:
1. Can both of these issues be corrected in the same procedure and through the same incision point?
2. Could a single vertical incision,essentially from point A to point C give better access to address both issues, or is a coronal incision still the method of choice?
3. I would be an out of town patient. If I were to go through with the procedure, how many days would I have to stay in the Indianapolis area for?
A: When it comes to skull reshaping, it is very common to simultaneously perform areas of reduction and augmentation. In answer to your specific questions:
- Both the sagittal ridge reduction and the occipital augmentation can be done through the same incision at the same time.
- The transverse coronal incision would be the standard approach. While there is nothing wrong per se with a sagittal or vertical incision, as equal access to do the procedure can be obtained as the coronal incision, there would be greater scar widening with that scalp incision orientation.
- You would be able to leave for home by 48 hours after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am concerned about my lack of volume and height in the back of my head. In order to achieve a more normal look, I am considering the two step occipital augmentation process with the tissue expander. Would this require me to take a month off of work? Have people been happy with the results? Is it possible instead to perform a series of smaller buildups to avoid having an expander in my head for a month?
A: When large amounts of occipital (back of the head) augmentation is desired, the limiting factor is how much the scalp will stretch to accomodate the bone buildup. This is overcome by the use of a tissue expander. By initially placing an expanding balloon, the scalp is slowly stretched to the desired amount. The same effect can not be achieved by serially building up the bone due to the scalp scar tissue that is created with the bone augmentation material. Most women have little problem with continuing to work through much of the tissue expander period because their hair masks much of the scalp expansion that is occurring. In the handful of patients with flat back of the heads that wanted a large amount of occipital augmentation, all have achieved greater volume and most were happy with the new shape of their heads.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: Dr. Eppley, I came across your website in search of a surgical procedure that would add more volume to the back of my head. (occipital augmentation) I have essentially a flat head, and would like to change that. My question is; what is the average price (I know they are not all the same) for this procedure.
A: The typical occipital augmentation procedure uses about 60 grams of bone cement (which is just about the extent that the scalp can stretch to accommodate the underlying bone expansion) placed over the flat area on the back of the head through a scalp incision. In most cases of occipital augmentation this produces a satisfactory result. However there are a minority of cases where this volume addition may not meet the aesthetic expectations of the patient based on the degree of flattening that they have. Thus it would be helpful to see a picture (side view) of your head to determine if this one stage approach would be enough. In more severe cases, a two-stage approach can be used but obviously we would like achieve a good enough improvement that only a single surgery is necessary.
As a general number, the average total cost of a cone-stage occipital augmentation procedure (all expenses included, surgeon’ fee, operating room and anesthesia and bone cement material costs) is around $8500.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation as well as temporal and back of the head augmentation. I like the way I look when I have hair, but sadly my hairline has began to recede. My forehead slopes back and I feel my head lacks the mass to balance my face (forehead and all) out. I’m interested both widening my temporal region (starting at about the ear back) with custom formed implants AND correcting relatively flat back. Can one incision be used for all three adjustments (left and right temporal and the back of the head)? And if so how large of incision would be needed and where would it be located?
A: I commonly have performed combined forehead augmentation and occipital augmentation. Dual access to both the back of the head, temporal and forehead regions can be done through a single scalp incision. It is known as a coronal scalp incision and runs across the top of the head from ear to ear. It effectively allows a ‘clamshell’ approach to be taken to skull rehabbing surgery and provides a 360 degree access and view of the entire head above the eye and ears. While it sounds and looks dramatic, it heals very well and quickly When looking at the patient the very next day when the dressing comes off, it is hard to image that type of surgical exposure that was done just the day previously. Patients also have a surprisingly minimal amount of discomfort afterward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in need of a back of the head skull reshaping procedure for the back of my head. When I cut my hair everybody can see the lump so I’m very frustrated about that and I like to know about this procedure to see what can be done to make that bone reduced in size by in filling around it. I was born like this and it has been there as long as I can remember. What can you do to fill around that bone is sticking out to reduce that size so make it look better? Thank you!
A: Skull reshaping of the back of the head is common for many types of contour issues. I believe the lump on the back of your head to which you refer is a variant of what I call the occipital knob deformity. This lump of thickened bone occurs at the confluence of the nuchal ridge line of the occipital skull in the midline. One could argue whether this bone is too thick or whether the bone that is around it is deficient, either problem of which makes it stick out. From reading your description, it sounds like your concept of contour improvement would come from building up the bone around it using a bone cement material. That is probably the most effective contour approach and would completely eliminate that appearance. That is a very straightforward procedure to do using about 30 grams of material through a small (8 to 9 cm) horizontal incision in the occipital area above the lump and could be done as a 90 minute procedure under anesthesia.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping. The occipital bone on my skull is flat and I am interested in correcting this, preferably with an implant. Surprisingly, you and a Korean clinic are the only 2 places I have found so far for this procedure. I have already ready about the risks and complications for elective surgery, I have read some of your blogs and had a few other questions. How many skull implants have you preformed and what complications have you seen? Do you recommend the putty over implants or no? I would worry that the putty would cause more complications and would be harder to remove if something went wrong. How much do you charge of this surgery? How long does the surgery take and what is the procedure? Could a rhinoplasty be combined with tis surgery and at what additional cost? If I opt for a rhinoplasty, would it be better to do the skull reshaping first and base the amount rhinoplasty on the new skull shape or vice versa? Thank you for your time and consideration.
A: Skull reshaping surgery is commonly done for a flat back of the head. When it comes to occipital augmentation for a flat back of the head, there are different types of augmentation approaches as you have mentioned. Bone cement or bone putty (PMMA or HA) and a preformed silicone implant can be used. There are advantages and disadvantages to either approach. Bone cements offer materials that do bond to the bone and can be impregnated with antibiotics as they are mixed intraoperatively which are their advantages. I have yet to see an infection with a bone cement cranioplasty. Their disadvantages are that they must be molded and shaped as they are applied as a putty so they can have some irregularities and palpable edge demarcations which is the number one reason a revision on them may occasionally be done. A preformed silicone cranial implant is perfectly shaped and its flexible characteristics makes it very adaptable to the bone without edge demarcations. Its softer material also allows it to be placed through a smaller incision. But the material does not bond to the bone and ideally should be secured in place by a small titanium screw. Its infection risk is somewhat higher and it is the only cranial implant that I have ever seen develop an infection and had to be removed. (one case)
Regardless of the material, both are easy to remove and the actual material cost is not significantly different. Most occipital cranioplasties take between one to two hours to perform and total cost will be in the $8,000 to $9,000 range.
Rhinoplasty can certainly be done at the same time as any skull reshaping surgery and actually commonly done, regardless of the type of rhinoplasty needed. If one separated the two procedures, the order that are done on does not make a difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in flat back of head surgery correction. I am ready to take the next steps for cosmetic skull augmentation surgery for the flat back of the head. I have a few concerns/questions and hoping you will be able to clear them for me. I have read the case studies and advice on your website and it gives me tremendous hope of having more normal head shape. My problem is that I have a rather flat back with bulges over both ears. My questions are as follows:
1) Based on your articles, I see you can build up 10 to15 mms on the back of the head in one attempt. I believe I may need more than 20 to 25 mms, so can you add 10 to 15mms in first attempt and then stretch the scalp further and in the second attempt add the remaining 10mm? Is that possible?
2) Is there ever of any possibility of this cranioplasty material getting loose? For instance if a person falls down etc.?
3) Will you be able to burr down the bulges on top of my ears? If so, how much?
4) I am a man who is starting to lose hair a little bit. Will the scar be substantial and show up?
5) What is the total time required for surgery and recovery if it is 10-15 mm augmentation versus a second attempt for the additional 10mm?
A: What you are describing is having a bilateral flat back of the head known as brachycephaly. (as opposed to flatness on just one side which is known as plagiocephaly) This is why you have bulges over both ears, the brain grew the bone out to the sides as opposed to pushing out normally in the back. This flat back of head surgery involves a build up across the back of the head with some width reduction. In answer to your questions:
1) If you need to have as much as 25mm of occipital bone buildup, you first need scalp tissue expansion and then secondarily add all the material volume needed. Once the scalp is lifted and stretched, its becomes scarred and will have little stretch. So trying to double the material volume later will not work. The choice is then settle for either two-thirds of what you need or make it a two-stage procedure.
2) Tiny titanium screws are first added to the bone and then the material is applied. This gives it something to forever be anchored, much like it done with construction concrete. Loosening of the material as yet to be a cranioplasty problem I have seen.
3) The protruding bone around the ears can be reduced about 5 to 7mms on each side.
4) While there is a scalp incision involved, it can heal remarkably well even in bald men. I am consistently surprised how well it heals in the scalp. Will there be a scar…yes. Will the scar be substantial…no.
5) The surgical time for a one-stage occipital augmentation is 2 hours. If it is a two-stage occipital augmentation procedure with a first-stage tissue expander the operative times are 1 and 2 hours respectively.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had a considerably flat occiput since infancy as I’ve noticed in pictures from that time. The vertex of my skull also slopes downwards towards the frontal lobe. This gives a “cone-shaped” appearance to my head when my hair is cut short. This has never been a concern to me, but in recent years I have began to develop male pattern baldness. Although I am currently taking drugs to hopefully slow its onset, I must be mindful of my skull shape should the treatment be ineffective. Having spent a considerable amount of time browsing your website, I’ve determined I may benefit from an implant to the occiput of my skull.
My questions are: what is the cost of such a surgery? Is there anything that can be done to flatten the vertex of my skull, or would an implant to the occipital lobe just exaggerate the slope? Would surgery require me to shave my head? Best and worse case scenarios, how big is the scar post-op?
I appreciate your time and consideration.
A: It is always more effective to augment the occiput than it is to reduce the vertex. While some bone reduction can be done, there is a limit based on the thickness of the skull to around 5 to 7mms of reducytiopn. The augmentation of the occiput can be as much as 15 mms. But put together a significant change can occur.
For skull reshaping surgery we do not shave any hair although we always appreciate any patients who would like to do so. As a ballpark figure the total cost of this surgery is in the range of $9500.
While all of these issues are relevant, none are more significant than the consideration of a scalp scar in a male. That is the key issue of whether this may be a good procedure for any patient but particularly in men who may have less hair to camouflage it. The scar is placed more to the back of the head keeping it within the stable hairline of most balding men. It is a long scar (12 to 14 cms) but thin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping if that´s possible. I´m a 45 year-old male and I wish to know if there is any procedure to implant some type of material at the occipital area in order to increase that part of my skull and make it a little more aesthetic, because I have that part very flat. I would also like to know if that would leave me with very visible scars? I would like my skull elongated in the anteroposterior axis. Thanking you in advance.
A: There are numerous methods of skull augmentation or expansion. They all rely on adding synthetic materials to the deficient skull area in the desired shape. The two basic methods are cranioplasty materials, such as PMMA (acrylic) and hydroxyapatites, and a custom-fabricated silicone or silastic skull cap or prosthesis. There are advantages or disadvantages to each approach which fundamentally comes down to cost and the ability to get a smooth contour and the maximal amount of expansion. The limiting factor in how much expansion can be obtained is how much the scalp can expand and to get a relatively tension-free scalp closure over the augmentation material. In my experience, a safe amount of skull augmentation is about 10mm in thickness. That may not sound like a lot but it creates an effect more significant than the number suggests. All of these methods require an open approach with a scalp incision to place them. This results in a fine line scar across the upper back of the head, somewhat similar to the location of a hair transplant harvest scar.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in building up the back of my head. It slopes backward and is flat and makes my head look asymmetric and unbalanced. I have attached pictures so you can see that the back of my head slopes downwards in an abrupt manner. By adding a round and nice piece my head would maybe look normal and my ears would even look smaller. But I have a few questions:
- So what would be the next step for me?
2. Seen from the pictures, do you assess that significant scalp stretch is required?
3. What if I’m active in sports and wrestle alot ie, is there a risk of misshape in the future?
4. What method do you feel is the most adequate for my head?
5. Would hair transplantation be necessary?
6. What is the recovery time?
7. What are the approximate costs?
I am aware that there may be scalp scars but that’s less severe than the current situation.
A: In answer to your questions:
1) The next step is to have either a phone or Skype consultation. This would be the best way to go over the different cranioplasty methods and their advantages and disadvantages. No cranioplasty method is perfect and each patient make make their choice based on good information. I have done occipital cranial augmentation by every conceivable method so I am very familiar with each of them and their indivdual pluses and minuses.
2) Stretch of the scalp is always needed because the material occupies space. The question is how much stretch can the scalp safely do. That is what limits how much material/augmentation can be achieved.
3) All cranioplasty materials set up and become solid like bone so no deformation will occur later with impact or trauma.
4) The best method for you require your understanding of each approach.
5) I do not envision hair transplantation being needed for the scar later.
6) The recovery is quite quick, being just a few days.
7) The cost will depend on the technique used, which is yet to be determined. The costs could range from $6500 to $9500 depending upon what cranioplasty material is used.
Dr. Barry Eppley
Indianapolis, Indiana
