Background: The scalp is a remarkably thick and well vascularized tissue as it covers the entire skull surface. Its thickness, however, varies at different areas of the skull. It is the thickest on the back of the head where it blends into the posterior neck tissues. The base of the occipital skull also ends up much higher than one thinks, leading to a thick collection of tissue over the back of the head without any underlying bone support.
Scalp rolls on the back of the head appear to occur due for a variety of reasons. Naturally thick scalp and neck tissues, excessive scalp laxity, short necks and being overweight can all contribute to a bunching up of scalp soft tissues in this area. Scalp rolls can appear as a single, double and even a triple roll. The most common presentation is a double roll with deep horizontal skin crease between them.
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Skin rolls on the back of the head is an almost exclusive male aesthetic concern. Shaved heads and very closely cropped hair make them visible and can be a source of embarrassment.
Case Study: This 28 year-old male had a thick neck with two very prominent scalp rolls with an intervening skin crease with his head in neutral position. It turned into a triple roll when he extended his head backwards. Presurgical markings were made of a elliptical excision incorporating portions of the upper and lower skin rolls with the skin crease at its horizontal middle.
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Under general anesthesia and in the prone position, an elliptical excision of scalp skin and a wedge of tissue was removed. The periosteum and some soft tissue was maintained on the bone for subsequent placement of quilting sutures at closure. The upper and lower skin flaps were undermined to release some of the additional skin rolls. Closure was done with quilting sutures to close the deep space as well as up to the skin level where a subcuticular closure was placed.
This excisional and undermining method will remove most of the skin rolls and create a smoother back of the head contour. While it does create a fine line scar, it appears similar to the horizontal skin crease that already existed.
Highlights:
1) Occipital scalp rolls can have multiple presentations from one to three rolls on the back of the head.
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2) Excision of a wedge of skin and deeper tissues allows for scalp roll reduction.
3) Widely undermining the scalp flaps above and below the excised tissues helps to work out adjoining rolls as well.
Dr. Barry Eppley
Indianapolis, Indiana
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