Q: Dr. Eppley, My daughter has Plagiocephaly that we were told would round out on its own and were refused helmet therapy. I saw your information about skull implants. I am very interested to know if this can be used on children, my daughter is 21 months. She has 10 mm asymmetry with flattening on her back right side and left forehead.
A: While skull implants can be made for plagiocephaly patients at any age, in young children with a lot of craniofacial growth yet to occur, augmentation of skull contour defects is best done by the application of intraoperatively shaped hydroxyapatite bone cements. These materials are more biocompatible with growing bone and will integrate into the bone as the process of appositional skull growth continues. I have seen case where bone has completely grown into and/or over such applied bone cements in children.
As a general rule I do not use synthetic preformed skull implants in patients who have not yet reached near complete craniofacial growth. While they are tremendously effective and make the surgery very predictable and allow for a quicker recovery, what happens to the bone around such an implant when applied at at early age is unknown.
Dr. Barry Eppley
Q: Dr. Eppley, I am 15 years old male teenager. I have a plagiocephaly flat head which wasn’t treated when I was a baby. I hate it so much especially in pictures as it makes my face looks lopsided. I can not go on with this face anymore as it is embarrassing. I don’t like going out because of it as I don’t like showing my flat side of my face. It is very horrible. There is not one single person that I know and that I have seen that has this type of plagiocephaly head. I need you guys to help please (:
A: While the effects of plagiocephaly are often most pronounced on the back of the head it often will have facial effects as well. Since plagiocephaly is really a twisting of the skull during development this can create numerous facial asymmetries as well. What is seen on the front of the face is often the mirror image of what is seen on the back of the head. This craniofacial condition is often more common that one would think. Because of your age under 18 years old) I can not communicate with you any further for treatment recommendations without parental consent.
Dr. Barry Eppley
Q: Dr. Eppley, I have some skull and face asymmetry from positional plagiocephaly. The main issue is that the right side of my forehead bulges, is it possible to reduce this bulging so my forehead doesnt have such a broad appearance when viewed from one side? Also the left side of my face is less prominent, maybe you could say “weaker” than the right. Would some sort of implant help with the asymmetry and make the left side as prominent as the right?
A: Plagiocephaly produces the exact face and skull asymmetry that you have described. Your right-sided forehead protrusion and smaller left face are common. Although I have not seen any pictures of you, your theory for improvement in facial symmetry would be the correct approach. Reduction of the right forehead bulging and augmentation of the left face, most likely that of the left cheek and jaw angle, could offer visible improvement. I would need to see some pictures of you, particularly a straight-on frontal view, to confirm if this approach would be helpful.
The left facial implants can be placed from inside the mouth so there are no scar trade-offs for those improvements. That can not be said for the forehead reduction in which the scalp scar trade-0ff must be considered very carefully, particularly in the a male patient.
Dr. Barry Eppley
What Plastic Surgery Procedures Can Be Done For Plagiocephaly In A Teenager For His Skull And Face Asymmetries?
Q: My son has torticollis which has contributed to his skull and facial plagiocephaly. We did not know about the cranial helmet when he was young and his condition was left untreated. He is now a teenager and very self conscious about his head being flat on one side and his face being skewed. He asked if there were any surgeries or anything we can do to correct it. I found your website and was amazed that you have experience with his exact condition. What can be done for him at this point?
A: Deformational plagiocephaly causes a very predictable pattern of skull and facial changes when untreated as an infant. As the craniofacial bones rotate around an axis, the pattern of asymmetries become flatness on one side of the back of the head and a protruding forehead, brow bone, cheek and jawline on the same side on the front. This can create very visible facial and front (forehead) and back (occipital) skull changes. I have seen a wide range of facial plagiocephaly problems in the degree of expression of the amount of asymmetrical differences.
Since the fundamental problem can not be reversed, changes must be done in an effort to camouflage or improve the different asymmetries. These can include an occipital cranioplasty to build up the flat area on the back of the head and numerous facial structural changes. The face can be altered by forehead and brow bone reshaping, cheek augmentation and jaw angle , and a chin osteotomy, all done with the objective of improving facial symmetry. The combination of skull and facial procedures that are helpful will be different for each patient. It requires an individualized assessment and computer imaging to determine the best plastic surgery plan for each patient.
Dr. Barry Eppley
Q: I am looking into bone recontouring for my forehead. I am 22 and I have a condition called Plagiocephaly that I have become aware of within the last few years. I have been to three different doctors who have all told me that they believe the condition is “minor” and doesn’t need any treatment. Not only does one side of the back of my head protrude outward more than the other side, but my forehead also does the same thing on the same side that my head protrudes. My brow ridge seems to be fine, but the bony part of the orbital socket (the part the eyebrow itself covers) seems to protrude more than the other orbital socket. It makes my forehead look very uneven. There also seems to be a flat spot on the side of my head right around my forehead region. I would like to know if this is fixable whether it be just fixing the forehead or fixing both the forehead and the back part of my head, but I also want it to look as natural as possible. Basically, I want it to look as close to what it should’ve been without Plagiocephaly. On a side note, I was also wondering why this condition has become noticable to not only me, but others as well, recently. Up until I was around 19 or 20, I had never heard anyone say anything about this to me, but it has become very apparent now. I understand that it has been like this since I was a baby, but I am wondering why it has become so apparent recently. Is it because the forehead hadn’t fully developed yet and thus became more distorted to the point of noticeability by the time I turned into my late teens to early twenties?
A: Plagiocephaly, known as a twisted skull, is a deformational skull shape that occurs in infants, evident either at birth or developing thereafter. Most commonly, it is the result of preferentially laying one side of the back of the head. Since the skull is very thin in infants, it can easily be inadvertently molded into an abnormal shape. That shape pattern is classic and you have described it perfectly.The side of the back of the head which is flat will cause the forehead on the same side to protrude. If significant enough, the shape of the eye (orbit) can also be affected.
What to do with this skull shape in an adult is a difficult problem. The bone is very thick and reshaping it is a major undertaking with long scalp scars. I would leave the back of the head flattening alone as the effort is not worth the result in most cases. The more visible front, the forehead, however, may be worthy of cranial reconstruction surgery (forehead reshaping) if severe enough. I would need to see photos to determine how severe it is and whether any surgery and its benefits is worth the risks. The biggest issue in forehead reshaping is whether a scalp scar is worth the trade-off.
The shape of your skull and forehead was determined long before you were fully developed. I do not think that it is more apparent now because it developed in your teens. I think it is more likely it has become apparent and now is a focus, making it seem it wasn’t there before.
Dr. Barry Eppley