Background: The sagittal crest is a common aesthetic skull prominence whose presence is magnified in the male with short hair or a shaved head. The sagittal crest comes in a wide variety of presentations from a small bump to a long elongated ridge. In many sagittal crests the head shape has an inverted V shape from the frontal view. Whether that is due to the crest alone or is the result of a parasagittal skull deficiency lateral to it which magnifies its existence must be determined on an individual basis. There often is an association between the two even if both do not necessarily need to be treated.
The sagittal bump is a limited variation of the longer sagittal crest. It can be an isolated raised area along a normal sagittal suture line or is just the highest and most bothersome part of a moderate sagittal crest. The sagittal bump can be reduced by a small incision made directly over it. Because of their limited size they can usually be completely removed/reduced.
Like the sagittal crest which may be associated with a parasagittal depression at its sides such skull indentations can also occur next to a sagittal bump creating a high-low contour change. The crest makes the dip look more indented and the dip makes the crest more prominent. An effective top of the head contour improvement can be done with a combination bump reduction and parasagittal dent augmentation.
Case Study: This male had a small sagittal crest/bump with a visible indentation to the right of the bump. The surgical goal was a bony bump reduction and dip augmentation done through the same small scalp incision.
Under general anesthesia and through a small zigzag scalp incision the thickened sagittal was burred down with a high speed handpiece and burr.
Through the same incision and using 5cc of quick setting hydroxyapatite cement the parasagittal indentation was augmented. The small scalp incision was closed with resorbable sutures without a drain.
When see days later before returning home the change in the top of his head profile could be seen to be much smoother.
The small scalp incision would go on to heal in an inconspicuous manner.
Aesthetic skull reshaping procedures cover a wide and diverse range of contour procedures. While may involve large skull surface areas there are actually an equal number of much small surface contour changes. These ‘spot’ skull contour changes, not surprisingly, are usually in males with shorter hairstyles for shaved heads. The key in any skull contour surgery is to make the operation match the size of the problem. This almost always refers to the size of the incision. As a result it is important to know how to do the procedures successfully through the smallest scalp incision possible.In other words very small skull contour problems need to have a correspondingly small incisional scar tradeoff.
Key Points:
1) A sagittal crest can occasionally be associated with a parasagittal contour defect.
2) Through the same small incision the sagittal crest and parasagittal augmentation can be treated.
3) Small parasagittal augmentations can be done with hydroxyapatite cement.
Dr. Barry Eppley
World-Renowned Plastic Surgeon