In any form of skull reshaping surgery scalp incisions are needed. While every effort is made to keep them as short in length as possible, some incisional length is needed with a resultant scar. Such scalp scars are unavoidable The question from patients is always what does the scar look like and how does it heal afterwards.
Incisional healing on the scalp from skull reshaping surgery is affected by many factors. These include the thickness of the scalp skin, hair density and hair shaft pattern, where on the scalp it is located and how the incision is surgically made and closed. No matter how the scalp incision heals from skull reshaping surgery it is important to realize that it will NOT look like many scalp scars appear after neurosurgery procedures. What one may find on an image search on the internet about scalp scars is almost always after neurosurgery procedures. While not a criticism of neurosurgery, scalp scars from aesthetic skull reshaping procedures is of paramount importance and are almost as important as whatever is done to the skull bone below it.
In my experience in performing aesthetic skull reshaping surgery, I have made ten observations about the resultant scars from the scalp incisions.
- Making the incisions with ‘cold steel’ (scalpels) has the lowest risk of injuring hair follicles. (lasers and electrocautery make for the worst scalp scars)
- Incisions must be made paralleling how the hair shaft exists the scalp to prevent injury to hair follicles.
- Closure of the scalp incision should be done with deep galeal sutures and either fine skin sutures or small metal clips. The dermis (underside of the skin) should not be sutured to prevent injury to hair follicles. There are no scar differences between small sutures or metal clips.
- Scalp scars do best on the top and back of the head. Scalp incisions on the sides of the head (temporal region) have a tendency to widen a bit in some patients.
- Scalp scars do very well in bald or shaved heads in men. They often do better than in patients with hair.
- Scar widening is more likely in skull augmentation than skull reduction procedures. Less tension on the wound closure equals a more narrow scar.
- Longer scalp incisions have a greater risk of scar widening than smaller scalp incisions, presumably due to the magnitude of the procedure done. Although more incision length in general increases the risk of scar widening by virtue of its greater length.
- Ethnicity does not change the risk of how the scar heals. Darker skin pigments do not have increased adverse scalp scars than that of Caucasians.
- I have never seen a scalp scar keloid, only scar hypertrophy. (widening)
- Repeated entry into the same scalp scar increases the postoperative risk of widening.
Dr. Barry Eppley
Indianapolis, Indiana