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Dr. Barry Eppley

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Case Study – Occipital Knob and Roll Reduction


Background: The back of the head is not usually given much thought as it not seen by most people including the person themselves. But in today’s world where many men now shave their heads, the entire shape of the skull takes on greater aesthetic significance than ever before. A smooth shape of the skull is now desired regardless of whether it is the front, top, sides or back.

occipital knob deformityThe back of the head, known as the occiput, is prone to a variety of misshapen issues. One of these is known as the occipital knob deformity. This is a well known aesthetic skull deformity where there is a bony projection in the midline at the bottom of the occipital skull along the nuchal ridge. It projects outward as a knob of bone and has also been called an occipital bun. In x-rays it can clearly be seen as a dense projection of bone disrupting the convex shape of the back of the head.

Why the occipital knob occurs is not known but it sticks out from the back of the head very prominently in some men. While it can occur just as an isolated bony skull deformity, it often has an excess of scalp tissue on top or above it. This roll of scalp tissue can be magnified since it sits down at the back of the head where it joins the neck. In thicker-necked men or men with thick scalp tissue, the occipital scalp roll can be just as significant an aesthetic issue as that of the bony projection.

Case Study: This 35 year-old male had a hard bulge on the back of his head as long as he could remember. It was not an aesthetic issue before he decided to shave his hair when it started to thin. Right under the projecting knob was a deep horizontal skin crease. Extending out from the sides of the knob was a thick skin roll.

Occipital Knob reduction intraopOccipital Roll Reduction intraop DR Barry Eppley IndianapolisUnder general anesthesia and in the prone position, the occipital reshaping procedure as done by initially incising along the existing horizontal sin crease. An elliptical full-thickness scalp excision was done exposing the underlying bony knob. The bony knob as reduced by burring to a smooth contour with the surrounding skull bone. Wedges of thick subcutaneous tissue was taken from both the upper and lower undermined skin flaps before they were closed in multiple layers with dissolveable sutures for the skin.

Occipital Knob and Roll Reduction result Dr Barry Eppley IndianapolisOccipital Knob and Roll reduction intraop Dr Barry Eppley IndianapolisIt is more common to have to remove scalp tissue when treating the bony occipital knob  than not. This is evident beforehand in men with short necks, thick scalp tissues and evidence of one or more horizontal skin rolls. The tradeoff in doing so is a fine line horizontal scar. But when a skin roll is present there usually is a deep skin crease anyway.


1) The bony occipital knob deformity on the back of the head is often associated with an excess of scalp tissue as well.

2) An occipital contouring procedure combining bony knob reduction with excision of excess scalp tissue produces a smooth convex back of the head contour.

3) This combined occipital knob and roll reduction procedure is done through a horizontal skin crease incision.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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