Background: While many perceive that the skull is round and smooth, the reality is that is oblong and often irregular in many people. The skull is prone to lumps and bumps that often occur at its sutural interdigitations or crossroads. The cranial sutures are the last areas of the skull that ossify, often well after birth and are active sites of bone deposition and resorption. This can create areas along their sutural path that are not smooth transitions between the different palates of skull bone.
One particular area of the skull that is prone to a non-smooth abnormality is the sagittal ridge or crest This is a raised area of bone that develops between the infantile areas of the anterior and posterior fontanelles. (soft spots) According to the Urban Dictionary a sagittal crest or a raised ridge of bone in the midline of the skull can be linked to narcissism or a higher intelligence and attractiveness. The reality is that it is either an aesthetic concern or it isn’t.
Anatomically the sagittal suture is located in the midline between the two parietal bones of the skull. It is frequently stated to be the attachment of the temporalis muscles and exists because of strong chewing function. In humans, however, this is not the attachment of the temporalis muscle (which is located to the side of the skull at the temporal lines) and is not affected by the chewing musculature. This suture takes a long time to fuse and does not occur until the second or third decade of life. As a site of long-standing bone activity, it can result in abnormal skull thickening creating a ridge or crest in the midline of the head at a late age. It can become noticeable in men that have short hair or shaved heads.
Case Study: This 26 year-old male was bothered by a high midline ridge on the back half of the top of his head. He felt that it made his skull look too triangular and not round like a normal skull. He had come to shave head due to hair loss and that is when it became very noticeable.
Under general anesthesia, a curved 7cm long scalp incision was made on the back of his head. Subperiosteal dissection was done along the ridge anteriorly until it became more flat which was about halfway from the front to the back. A handpiece and burr was used to reduce the ridge 7mms along its length. The diploic space was not encountered along the length of the reduction. (close but not entered) The reduced bone surface was covered with bone wax to prevent any postoperative oozing which can be a stimulus for bone formation. The procedure was completed in one hour and compressive head dressing was placed for the first note after surgery. He went home as an outpatient.
In summary the sagittal crest is an aesthetic deformity caused by a midline bony protrusion that can be reduced through a small incision in the scalp. It is a safe and effective minor skull reshaping procedure.
Case Highlights:
1) A prominent sagittal ridge or crest is the result of how the sagittal cranial suture fuses, often becoming thick and raised.
2) A thickened sagittal suture creates a visible ridge from behind the forehead back to the original posterior fontanelle area often creating a peaked or triangular shape.
3) The sagittal crest can be reduced by burring it down along its length with the amount of reduction between 5 to 7mms in most cases.
Dr. Barry Eppley
Dr. Chris Ueno
Indianapolis, Indiana