After having taken you on a journey through the cranial nerves, I am going to take you on a ride around the brain, doing a deep dive into the substance of it, and after that, we will run down the entire spine. Just like there are 12 cranial nerves, there are 33 vertebrae—so hold on tight.
Let’s start with the scalp, an underrated piece of real estate. Five neat layers—Skin, Connective tissue, Aponeurosis, Loose areolar tissue, and Pericranium—work silently to protect the skull and all the important meetings happening inside. Most people ignore it until something grows on it that shouldn’t. My greatest regret is that what’s supposed to grow on it, doesn’t: hair!
Rani, a sprightly 62-year-old with the energy of a woman half her age and the hairstyle of someone who had been too busy living to care much for grooming, came to see me on a rainy afternoon. She was wearing a bright floral kurta, carrying a cloth bag, and smiling conspiratorially. She leaned forward across my desk, lowering her voice: “Doctor, I have brought you a samosa.” I raised an eyebrow: food bribes are not standard medical practice, and come to think of it, you can’t seduce a Parsi with vegetarian food! She tapped the top of her head. “It’s here.” Parting her hair with two fingers, she revealed a smooth, dome-shaped swelling about the size of a small gulab jamun.
Imaging: Deni Lal
It sat smugly on her scalp, just off-centre, like a badly placed cherry on a cake. “It’s been growing for years, but now it’s become painful,” she said. “My husband calls it my second head.” I took one look at it and explained that it was a sebaceous cyst—a harmless sac filled with keratin and sebum, the skin’s natural oils. She looked relieved.
“So, you will just squeeze it out like toothpaste?” she asked. Not quite. I told her we’d have to remove it surgically, because squeezing it would be messy, partial, and likely to return.
“Can we do it now?” she sprung at me. “We can do anything,” I told her.
In the next hour, in the minor OT, she lay comfortably prone while I infiltrated the area with local anaesthetic. She chatted about her neighbour’s son’s wedding while the numbing took effect. The cyst was just beneath the skin, but the scalp is a notorious bleeder, richly supplied with vessels. The trick is to plan the incision so that you don’t nick a major one and turn the table into a Holi celebration.
I parted her hair with the precision of a hairstylist, then made a neat elliptical incision over the swelling. The skin opened like the crust of a well-baked pie, revealing the pearly white dome of its wall. Sebaceous cysts have their own personality. Some are shy and slip out whole; others are stubborn, tearing as you coax them, releasing their contents in an olfactory event you don’t soon forget. This one was somewhere in between—firm, but not hostile. I slid my scalpel gently around its capsule, freeing it from the surrounding connective tissue. Each sweep was deliberate, avoiding rupture. Beneath my fingertips, the cyst felt like a hard-boiled egg still in its shell.
Once I’d freed its base, I lifted it out in one satisfying, intact piece. I dropped it into a metal tray with a soft plink.
We irrigated the wound, checked for bleeding, and closed it with fine stitches. A small dressing covered the site. When she sat up, Rani reached up to touch her head. “It’s flat!” she exclaimed. Her son, who’d been waiting outside, walked in and asked, “Where’s the samosa?” I showed him the cyst in the tray. He made the universal Indian face for I wish I hadn’t asked.
Before leaving, she said, “Doctor, for the first time in years, I can lie on my pillow without feeling like I’m crushing a ladoo.”
The scalp may seem like a trivial starting point in our journey through the brain’s layers, but it has its own dramas. From simple cysts to serious lacerations, it is the first and most visible line of defence. And like many things in medicine, the humble can be deceptively important.
Sometimes, the best surgical victories are not in the deepest recesses of the brain, but in removing a small, stubborn lump that’s been part of someone’s daily life—and haircare routine—for years.
The author is consultant neurosurgeon at Wockhardt Hospital, Mumbai.
mazdaturel@gmail.com @mazdaturel