Surgical Anatomy of the Ligamentous Attachments in the Supero-posterior Scalp Region

Abstract Background Hairline-lowering surgery has become increasingly popular in recent years, but little investigation into the surgical anatomy of the scalp has been performed. Objectives The aim of this study was to describe findings based on clinical observation and anatomic study of ligamentous attachments in the superoposterior region of the scalp. Methods Six fresh cadaveric heads were dissected to identify connective tissue structures in the superoposterior scalp region. The areas of interest were along the sagittal suture towards the lambda, the obelion, and around the lambdoid suture. The location and dimensions of identified connective tissue attachments were documented with reference to described skeletal landmarks. Results Three distinct structures could be identified: (1) a cylindrical structure that sits at the posterior end of the sagittal suture with the parietal foramina in its base. This ligamentous structure extends from the pericranium into the galea, causes dimpling in the skin, and contains emissary veins. As this fulfills the criteria for an osseocutaneous retaining ligament, the term “cranial retaining ligament” is proposed. (2) Anterior to this ligament a connective tissue thickening was identified running along the sagittal suture and blending into the ligament, for which the term “sagittal adhesion” is proposed. (3) Another adhesion was identified just superior to the lambdoid suture, posterior to the retaining ligament, for which the term “supralambdoid adhesion” is proposed. Conclusions Identification and better understanding of ligamentous structures in the superoposterior scalp allows for a safer and more effective advancement of the scalp in hairline-lowering surgery, which is a benefit to both patients and surgeons.