Q: Dr. Eppley, First of all, thank you for the more than complete information you provide in your websites. It is very useful for those of us who need information about surgical procedures that are not usually offered by most plastic surgeons. My problem is that I suffer from plagiocephaly, with the right back side of my skull flattened (comprising the occipital, parietal and temporal bones) and the right side of my face being more prominent (forehead, orbital rim and cheekbone) than the left one. Although I have found extremely useful all the information collected in your websites, I have some questions:
1. In occipital augmentation, and when a single custom implant (due to the extent of the malformation) must simultaneously cover the occipital, parietal and temporal regions, taking into account that the temporal bone is covered by muscle and that the occipital and parietal zones do not, between which layers is the implant inserted, I mean, over which layers does the implant sit?
2. I have read in your posts that the “bony suboccipital” area (the lower area of the occipital bone that is below the neck muscles and below the superior nuchal line) can’t be augmented due to possible neck muscles problems, but is there any reliable and permanent “muscular suboccipital/subnuchal” augmentation method? Could a custom silicone implant (or semi-custom hand-carved) be placed over the upper neck muscles? Would this implant sit directly over the muscle or in another plane? Over what muscle/s? What durometer silicone implant would be required? Would fat grafting be another permanent option? Would this fat be injected in a submuscular or in a subdermal plane? Would a first previous stage of scalp expansion be necessary or recommended?
3. In the case of the face, is it possible, by burring technique, to reduce the horizontal projection of the anterolateral region of the forehead and the horizontal projection of the orbital rim (superior, lateral and inferior areas, from the supraorbital notch to the zygomaticomaxillary suture) (black painted areas in the attached picture)? And how many mm approximately?
Thank you very much for your time and patience.
A: In answer to your questions:
1) Any skull implant that covers a combined non-muscle and muscle areas must go on top of the temporalis fascia.
2) As a general rule there is little aesthetic value to having a skull implant go much beyond the nuchal ridge line of the occiput onto the neck muscles and there are potential complications from doing so. Any soft tissue neck deficiency below the nuchal ridge must be treated by conventional soft tissue augmentation methods (fat injections) although they work poorly in the tight posterior neck area.
3) You are going to get roughly 5 to 6mms of bony reduction on the highlighted forehead and orbital regions.
Dr. Barry Eppley
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