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Background: The skull develops through numerous methods, one of which is ossification of certain bony eminences. (aka primary bone growth centers) One of these is the well known parietal eminence area which ultimately forms the large parietal bones of the skull. These quadrilateral-shaped skull bones located at the sides and posterior roof of the skull have four borders. But at its very center and the most projecting area is the original parietal eminence area.

Everyone has parietal eminences but they vary in size and projection on each individual. For a few select people they project outward more and can be of an aesthetic concern, making a visible projection from the side of the head most clearly evident in the frontal and oblique views. Understandably in the shaved head male prominent parietal eminence areas create easily seen protrusions. But in my experience females present just as frequently with this skull protrusion concern and they have complete hair coverage of them. But yet this specific site of skull protrusion is just as concerning to them. 

The parietal eminence has reasonable bone thickness so it can be effectively burred down. But the eminence runs over into the posterior-superior temporal area on the side of the head so the muscle and fascia in this area must be removed as well for a good reduction/flattening effect. While the parietal-temporal eminence reduction is straightforward in the female patient it comes with the danger of working within hair with high speed instruments. No hair is ever removed for this procedure so there are a series of steps down to prevent the very adverse consequence of hair avulsion from the high speed drill.   

Case Study: This middle-aged female had long been bothered by her prominent parental eminences and had made numerous lifestyle/habit adjustments to work around these aesthetic head shape concerns. (always wore bangs, wouldn’t be seen with wet hair, careful in the wind etc)

Under general anesthesia her hair was initially moistened and placed in a pony tail. A wavy 5cm incisional marking was done over the parietal eminence areas where the hair naturally parted from the pull of the ponytail. The incision was made with a scalp and once past the hair follicles electrocautery was done down to the bone. The temporal fascia and muscle was removed below the temporal line for complete exposure of the skull protrusion.

Once good exposure was obtained a towel was placed over the area, a slit cut through it along the underlying opening and the edges of the incision stapled to it, (maximal hair protection. The shaft of a high speed drill was guarded with plastic tubing.

Then in a linear fashion  the entire skull protrsiion was widely reduced until the area was distinctly flattened. After removing the bone dust by irrigation the scalp incision was closed in two layers with resorbable sutures.

One of the important elements in aesthetic skull reshaping surgery is to limit the size of the incision and almost never shave/remove hair. Skull reductions in a female usually add the issue of longer hair where high speed burring could inadvertently cause traumatic hair avulsion. A series of intraoperative maneuvers as described in this case are necessary to eliminate that aesthetic risk.

Case Highlights:

1) Parietal eminence protrusion reduction is not an uncommon request in female aesthetic skull reshaping surgery.  

2) Satisfactory reduction is a function of parietal-temporal prominence/line reduction and removal of the overlying temporalis muscle.

3) In female skull reductions protection of the hair from high speed burring equipment is a critical part of the procedure and variety of strategies are available to do so. 

Dr. Barry Eppley

World-Renowned Plastic Surgeon

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