Post on 12-Nov-2015
Preface
Aesthetic considerations in cranial neurosurgery
Guest Editor
There is no question that the attention of a
neurosurgeon should be focused on the pathologic
ndings at hand when treating intracranial disease.
This includes designing the safest approach that
provides the necessary exposure to treat the patho-
logic ndings adequately. Although a secondary
consideration is the patients appearance after
having an operation for a life-threatening condi-
tion, it is a consideration nonetheless. For many
patients undergoing elective procedures, this is
quite a prominent consideration.
Too many neurosurgeons ignore the cosmetic
aspect of their surgery. This issue is extremely
important, however, because more than ever in
neurosurgery, the quality-of-life issues and mor-
bidity of surgery are prime considerations in
patients discussions regarding open surgical treat-
ment versus alternative treatment, such as radio-
surgery, when they have a choice. With modern
drill and instrument technology as well as contem-
porary imaging techniques, unnecessarily disgur-
ing neurosurgical procedures should be a thing of
the past. The goal of this issue of Neurosurgery
Clinics of North America is to discuss the myriad
of contemporary neurosurgical techniques that
exploit the newer drill and instrument technology
to provide the same tumor resection and preserva-
tion of critical structures but, at the same time,
have the patient appear as though he or she has
had no operation at all. Included in this issue is
the design of scalp incisions; scalp aps; minimal
hair-shaving techniques; craniotomy ap design
minimizing bone loss and cosmetic deformity;
reconstructive techniques, including newer materi-
als such as hydroxyapatite cement; and cranio-
facial osteotomies for additional exposure with
the preservation of normal facial contour once
the reconstruction is performed.
As is the case with other areas of neurosur-
gery, neurosurgeons can gain valuable techni-
cal information and expertise from other related
disciplines, such as orthopedic surgery for spinal
instrumentation and otolaryngology for skull base
surgery. In this issue, signicant contributions
are presented by plastic surgeons who are ex-
perts in craniofacial, esthetic, and reconstructive
surgery.
Some neurosurgeons are not aware of all
these techniques and their implications in relation
to patient satisfaction after a neurosurgical pro-
cedure. A prime example from my personal ex-
perience involved two patients, one of whom
had undergone tumor resection using techniques
with an eye toward the esthetic result, where there
was no postoperative cosmetic deformity, and a
second patient who had a similar tumor resected
but whose head was completely shaved and who
had an obvious craniotomy defect in her fore-
head with atrophy of her temporalis muscle. These
two patients had their follow-up MRI scans on
the same day, and once they realized that they
had almost identical tumors resected by dierent
Christopher A. Bogaev, MD
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Neurosurg Clin N Am 13 (2002) ixx
surgeons using remarkably dierent techniques,
the second patient was extremely disappointedwith
her result, despite the same functional outcome.
Minimally invasive techniques in neurosurgery
are gaining popularity as well as utility. This same
attitude should be carried over to large tumors
requiring large operations, in that the use of the
techniques discussed in this issue can help to re-
duce the cosmetic deformity resulting from these
procedures and increase patient satisfaction and
quality of life. The more that morbidity is reduced
from a neurosurgical procedure and the quicker
that patients are returned to mainstream daily
living that includes not attracting attention in a
crowd from a cosmetic deformity, the more pa-
tient satisfaction will improve. This can be a ma-
jor factor when patients are weighing treatment
options, such as radiosurgery versus open surgery.
If they know that the tumor can be removed and
that they will look the same as they did before
surgery soon after surgery, the choice for surgery,
if it is indicated, may be easier for them and less
anxiety provoking.
The topic of this issue represents a relatively
overlooked but increasingly important area of
neurosurgery. Hopefully, this issue will bring
this topic to wider attention and spark further
discussion and development of these issues and
techniques.
Christopher A. Bogaev, MD
Division of Neurosurgery
University of Texas Health Science Center
at San Antonio
4410 Medical Drive, Suite 610
San Antonio, TX 78229-3798, USA
E-mail Address: CAB@neuroassocsa.com
x C.A. Bogaev / Neurosurg Clin N Am 13 (2002) ixx
The cosmetic aspects of neurosurgeryLaligam N. Sekhar, MD*
Mid-Atlantic Brain and Ear and Spine Institutes,
3301 Woodburn Road, Suite 202, Annandale, VA 22003, USA
Advances in neurosurgical operative tech-
niques and instrumentation have resulted in great
improvement in patient outcome after surgery. It
is important, however, for patients to return to
normal life. As explained in this article, recent
modications of neurosurgical techniques have
permitted patients to return to everyday life, and
attention needs to be paid to the cosmetic aspects
of neurosurgery.
Although the advances in neurosurgical opera-
tive techniques and instrumentation are achieved
with great improvement in patient outcomes after
surgery, considerable attention needs to be paid to
the cosmetic aspects of neurosurgery. For a neuro-
surgical patient to return to normal everyday life,
it is important that the patient looks as normal
or as close to normal as possible. Many recent
modications of neurosurgical technique have per-
mitted this.
Hair shaving
For most neurosurgical operations nowadays,
we shave just a strip of hair along the line of inci-
sion unless it is an area where the operative site is
completely covered by the patients natural hair
(ie, retrosigmoid craniotomy).
The hair in the skin ap that is being reected
can be divided into small locks and taped onto the
patients face or braided and taped. The hair itself
shouldbeprepared ina sterile fashion in the surgical
eld. It is a good idea for the patient to have a good
hair shampoo the night before surgery.
Skin incisions
Incisions made in the scalp should always be
made behind the hairline. This may represent a
problem in patients with receding hairlines. Addi-
tionally, the incision should respect the territory
of major arteries and veins that supply the scalp
(ie, the supercial temporal artery and the occipital
artery) so as to preserve the blood supply. In gen-
eral, the base of the incision should always bemuch
wider than the apex to avoid skin necrosis. When
the incision is extended in the preauricular area, a
curve that follows the ear is followed to avoid rec-
ognition of the line of incision at a later time. The
human eye discerns a straight line much better than
a curved and broken line, and incisions that are
made in this fashion (curvilinear) are not really
visible. Additionally, incisions should be less than
0.5 cm in front of the tragus of the ear to avoid
damaging the frontalis branch of the facial nerve.
Cranial nerve problems
It is important to avoid damaging cranial ner-
ves VII and V (especially corneal numbness).
Obviously, damage to cranial nerves III and VI is
also of great cosmetic disadvantage. Cranial base
osteotomies should be planned in such a way that
the reconstruction is adequate to avoid cosmetic
problems. This is described later in this article.
Temporalis muscle
Whenelevated from the temporal fossa, the tem-
poralis muscle should be elevated as carefully as
possible to avoid damage to its blood supply and
its nerve supply. In most cranial base cases, we pre-
fer to elevate the entire temporalis muscle to avoid
damaging it. If the muscle has to be split, it is split
along the bers so that it is not damaged. Damage
* 3301 Woodburn Rd., Suite 202, Annandale, VA
22003, USA.
E-mail address: Lsekhar@aol.com (L.N. Sekhar).
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Neurosurg Clin N Am 13 (2002) 401403
to the motor branch of the temporalis muscle may
result in atrophy. A secondary reconstruction is
sometimes necessary after several months.
Craniotomy aps and reconstruction
When a craniotomy is performed, it is im-
portant that it be performed adequately without
dural tears, especially because many burr holes
and dural separation are performed as necessary.
When the craniotomy aps are reaxed, however,
we use the combination of titanium mesh and one
of the dierent types of bone cement (eg, Bone
Source cement; Leibinger Company, Freiburg,
Germany) to avoid a cosmetic deformity. Even
over burr hole sites, either burr hole covers or tita-
nium mesh is used to avoid stinging, which is par-
ticularly bothersome to the patient. Microplates
should be avoided if possible in the forehead area.
Obviously, all precautions should be taken to avoid
infection of craniotomy aps so that the aps are
not lost.
Cranial base repair
It is important that cranial base operation repair
be performed meticulously using vascularized and
nonvascularized tissue. If the repair is not perfor-
med adequately, there is a possibility of epidural or
subdural infection, which may result in prolonged
hospitalization, death, or cosmetic problems.
Specic operative approaches and incisions
Cervical incision for carotid exposure
For carotid exposure in the neck, when it is per-
formed for either proximal control or bypass pur-
poses, we prefer to make an oblique skin crease
incision rather than a vertical incision. When
healed, this is generally barely visible to others.
Forearm and thigh incisions for radial artery
and vein graft extraction
Incisions in the forearm and/or the thigh for
the extraction of radial artery and vein grafts
are presently unavoidable. Although an endosco-
pic technique for extraction of vein grafts has
been described, we are not comfortable at the
present time in using this technique with the avoid-
ance of injury to the various branches. The inci-
sions should be carefully closed in multiple layers
so as to avoid spreading. If the result is considered
unacceptable by the patient, subsequent plastic
surgery repair may be indicated.
Frontotemporal craniotomy
During frontotemporal craniotomy, we gener-
ally employ a preauricular and frontotemporal
incision, which extends up to or just beyond the
midline depending on the wound ap to be used.
We do not prefer any incisions in the eyebrow or
forehead, because these are quite unsightly in some
patients. When well healed, most frontotemporal
incisions are barley visible or not visible at all
sometimes even to the surgeon.
Orbital osteotomy
We prefer to perform an orbital or orbital zygo-
matic osteotomy in two pieces. It is easier to per-
form the osteotomy in this fashion. Additionally,
at least two thirds of the orbital roof and lateral
wall can be removed and replaced such that
endophthalmos can be prevented. If there is exces-
sive loss of orbital bone because of tumor invasion,
secondary reconstruction using titanium mesh is
essential to avoid endophthalmos. In such pa-
tients, both eyelids should be sutured shut and
left visible in the operative eld so that they can
be checked at the end of the operation to make
sure that there is no pulsatile endophthalmos or
exophthalmos. When zygomatic osteotomy is per-
formed, it is a good idea to place the plates before
the osteotomy cuts are performed so that they can
be adequately reapproximated.
Transpetrosal and translabyrinthine approaches
During these approaches, which require a pet-
rous bone resection, reconstruction can be per-
formed at the end of the operation in one of two
ways. We currently prefer to remove the outer
mastoid cortical bone as a single piece before the
deeper mastoidectomy. This does carry some risk
of damaging the sigmoid sinus, however. A simple
method of reconstruction is to use titanium mesh,
autologous fat graft, and, if necessary, Bone
Source cement. If such reconstruction is not
employed, the patient subsequently has an
unsightly sinking behind the ear as well as some
displacement of the pinna such that he or she is
unhappy with the results. In such patients, secon-
dary reconstruction needs to be performed.
Retrosigmoid approach
We prefer a C-shaped incision for both the
retrosigmoid approach and the extreme lateral
402 L.N. Sekhar / Neurosurg Clin N Am 13 (2002) 401403
approach such that the skin ap is located away
from the main dural entry site so as to reduce the
prospect of cerebrospinal uid (CSF) leakage.
The C-shaped incision also allows the elevation
of the muscles from their attachments in layers
rather that cutting through the muscle, which is
an important cause of postoperative headache.
When it is not possible to remove the entire cra-
niotomy and replace it, there is a denite amount
of bone loss, and reconstruction is performed at
the end with titanium mesh and bone cement. This
avoids any cosmetic problems and also the post-
operative headache syndrome, which has been
described with the retrosigmoid approach.
Extreme lateral approach
With this approach, the main source of cos-
metic problems is damage to the hypoglossal nerve
and spinal accessory nerve. Damage to the spinal
accessory nerve should be carefully avoided during
the early part of the exposure.
Transfacial approaches
We generally do not prefer a transfacial ap-
proach, because the incisions are dicult to con-
ceal. When a transfacial approach is performed,
it is preferable to use the midface degloving ap-
proach, because the incision is located in the sub-
labial area. In particular, the facial translocation
approach may result in cosmetic deformity as a
result of atrophy of the muscles, frontalis nerve
palsy, and/or trismus with diculty in opening
the jaw. When the transfacial approaches are
performed, the incisions should be made by an
ear, nose, and throat surgeon well trained in facial
plastic techniques.
Summary
The cosmetic aspects of neurosurgery are
important and make a considerable dierence to
the patients quality of life. In general, the saying
is true that at a cocktail party, the patient should
not be recognized as having had neurosurgery, or,
even better, the patients own neurosurgeon
should not be able to detect which side the patient
was operated on when the patient is seen in the
oce 6 months later without looking at the
chart.
403L.N. Sekhar / Neurosurg Clin N Am 13 (2002) 401403
Cosmetic considerations in cranial surgery:plastic surgical perspective
Deepak Narayan, MD, John A. Persing, MD*Section of Plastic Surgery, 330, Cedar Street, Boardman Building-330,
New Haven, CT 06520, USA
This article is an overview of the recent advan-
ces and cosmetic implications of various aspects
of craniofacial surgery from a plastic surgical
viewpoint.
The interaction between plastic surgeons and
neurosurgery colleagues has traditionally been
in the management of problem wounds. More
recently, the arcs of neurosurgery and plastic sur-
gery have intersected in the techniques of craniofa-
cial surgery (eg, congenital anomalies, cranial base
tumors, craniofacial trauma), which has resulted
in a fruitful cross-pollination of ideas that have
beneted both the patients and the specialties.
Integral to this interaction is the concept of a
team, whereby diering perspectives based on clin-
ical experience contribute to the formulation of the
therapeutic plan. The role of communication in
this milieu cannot be overstressed. This includes
communication between the plastic surgeon, the
neurosurgeon, and other members of the team so
as to dene the plan, followed by a thoughtful pre-
sentation to the patient. Emphasis on risks as well
as benets results in a more informed patient who
is more likely to contribute to his/her care after
surgery. This approach has assumed greater im-
portance in the information age, where ready
access to some information on virtually any sub-
ject is available on the Internet. The teams gui-
dance of the patient and his/her family through
conicting, hyperinated, or occasional misinfor-
mation is needed for them to be appropriately
informed.
Scalp
Shaving of the head before intracranial proce-
dures has been a part of neurosurgical custom for
some clinicians. In our practice, when dealing
with most craniofacial patients, we have stopped
shaving hair and have seen no increase in infectious
complications inwell over twodecades [1]. Clipping
approximately a centimeter on either side of the
incision in patients with long hair can facilitate
wound closure, however. This has the trade-o of
a scalp deformity, which may not be accepted by
young adults. Patient response has been most grat-
ifying when hair is not removed, relieving consider-
able anxiety about postoperative appearance. This,
we believe, promotes psychologic well-being and a
faster recovery, because the patients have one less
of the operative stigmata to concern them.
Incisions
We remain unconvinced about the superiority
of the electric scalpel [2] compared with standard
scalpel incisions in the scalp. We believe that the
heated scalpel may cause greater thermal injury,
potentially leading to greater incision line alopecia
and infection [3]. Certain principles pertaining to
scalp incisions have stood the test of time, yielding
better cosmetic results. Incisions throughhair-bear-
ing areas should be beveled at an angle parallel
to the hair shafts to reduce localized alopecia. In
making an incision where there is hair on one side
and glabrous skin on the other, the incision should
be beveled away from the hair-bearing side so that
the hairless skin can be brought over cut hair
shafts such that when they regrow from the
retained follicles, they grow through the glabrous
skin, thus hiding the incision.
* Corresponding author.
E-mail address: john.persing@yale.edu
(J.A. Persing).
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Scalp defects
Small scalp defects are best treated with local
aps (rotation, transposition, or advancement).
Rotation aps, such as Orticocheas three-ap
and four-ap [4,5] variants, are reserved for those
defects that cannot be closed by simpler techniques
primarily on account of their size. Local aps are
dissected in the subgaleal plane. Galeal scoring
of these aps can produce up to a 20% increase
in coverage area. In a series of publications, Juri
[6,7] has described a number of scalp aps, origi-
nally proposed for male pattern baldness, that
can be usefully adapted to provide coverage of the
frontal or frontoparietal region with hair-bearing
skin. The so-called delay phenomenon, a surgical
procedure whereby the outlines of the ap are
incised but not raised in an eort to improve
vascularity by dilatation of the remaining blood
vessels, is a necessary adjunct to the use of these
aps [1]. The physiologic basis of the delay pheno-
menon is poorly understood. Postulated mecha-
nisms include an increase in the size and number
of vessels and vasodilatation secondary to sympa-
thectomy [8]. Areas of cicatricial alopecia may be
directly excised and closed if tension is suciently
relieved. Large defects can be excised and resur-
faced in a staged fashion using tissue expanders.
One must be wary about the eects of prolonged
pressure of tissue expanders on the underlying
skull, however, because secondary deformity may
be produced on the skull surface. These defects
are generally mild, however, and return to normal
on removal of the expander. Scalp tissue can be
re-expanded and readvanced after a previous
expansion. Apparent loss of expanded skin during
advancement by recoil of soft tissuemandates over-
expansion by approximately a third in an eort to
compensate for this shrinkage [9].
Pedicled muscle aps play an important role in
the coverage of infected wounds or exposed dura.
The benets of a pedicled myocutaneous ap re-
late to the bulk of fresh tissue with an independent
blood supply that can be brought into a usually
compromised vascularity without the complexity
of a microvascular anastomosis. This is a distinct
advantage compared with local aps, which may
become compromised by radiation scar or tra-
uma, but is achieved at the cost of a donor site de-
formity. There are a limited number of pedicled
aps that can be used to cover cranial defects, how-
ever. A useful example is the trapezius ap, which
is pedicled on the transverse cervical artery and of-
fers excellent coverage of posterior cranial defects.
Massive scalp losses, such as those resulting
from scalp angiosarcoma extirpation, for example,
are best treated, in our opinion, with free-ap
reconstruction using a at muscle, such as the
latissimus dorsi. The muscular bed is an ideal re-
cipient site for a split-thickness graft, and after
denervation atrophy of the muscle, an excellent,
albeit glabrous, contour is obtained.
Microsurgical replantation of the scalp is the
procedure of choice for total scalp avulsion. This
represents the best possible match in terms of ap-
pearance and function, because no other tissue in
the body can substitute for the hair-bearing scalp.
The entire scalp can survive on a single blood ves-
sel, such as the supercial temporal artery. The
procedure, however, demands microsurgical skill
that might not be readily available.
An ischemia time of greater than 30 hours
is considered a contraindication to replantation
[10]. Other indications for microvascular tissue
transfer for scalp wounds are unavailability of
local aps for coverage (eg, the cranial base),
failure of pedicled muscle aps used to treat os-
teomyelitis of the skull, or radiation damage. The
advantage of free aps is that they can bring in
large volumes of fresh tissue and an independent
blood supply, thereby bypassing the local condi-
tions that interfere with healing. The operative
procedures are time-consuming, require a high
degree of technical skill, leave a donor site defect,
and may, on occasion, demand anticoagulation,
which results in bleeding problems if done in con-
junction with intracranial procedures.
Skin substitutes
We make liberal use of allograft skin as a tem-
porizing measure during the excision of scalp
tumors, such as dermatobrosarcomas, where
margins are unreliable on frozen section analysis.
This permits coverage without loss of precious
adjacent native skin and, consequently, a larger
cosmetic defect at the harvest site should a wider
resection be mandated by the permanent section.
We believe that allograft (banked human cadaver
skin) is readily available, more durable, and less
costly than currently available tissue-engineered
skin substitutes.
Planning incisions
Access to the cranium involves consideration
of the triumvirate of speed of access, width of
406 D. Narayan, J.A. Persing / Neurosurg Clin N Am 13 (2002) 405410
exposure, and cosmesis. A number of incisions/
approaches are currently at the neurosurgeons
disposal, providing access to regions, particularly
the cranial base, that were previously thought to
be inaccessible. The facial translocation techniques
as popularized by Janecka and his colleagues
[11,12] and the midface degloving technique are
cases in point. In deference to cosmetic concerns,
we have, for instance, eschewed the use of open
sky incisions, eyebrow incisions, and subciliary
incisions for access to the periorbital region or
the oor of the orbit, instead using the transcon-
junctival or blepharoplasty incision with a crows
foot extension.
Placement of scalp incisions should take
current hair patterns into account. In general, cra-
niotomy incisions should be placed no closer than
3 cm from the glabrous border in the hair-bearing
scalp. Incisions closer to the border are readily
visible and unsightly, but if circumstances dictate
a need for a closer position of the incision line,
it is best to make the incision directly in the inter-
face between the glabrous skin and hair-bearing
scalp.
Such operative ideals may be moot when speed
is paramount, as in cases of severe cerebral tra-
uma. Excessive emphasis on obtaining the perfect
cosmetic result at the cost of signicantly pro-
longing operative time should be avoided. In most
cases of trauma, however, appreciation of the cos-
metic result should be factored into the quality-of-
life result.
Soft tissue supplements
The ideal alloplastic material should be
strong, nonallergenic, readily available, noncarci-
nogenic, nonreactive, pliable, infection resistant,
and moldable, and it should eventually be incorpo-
rated into the body. Such a material currently does
not exist, although there are some that possess
a few of these attributes. The popularity of these
products is a result of their ready availability and
lack of donor site morbidity. The introduction of a
foreign body into the soft tissue, however, always
carries with it the risk of local tissue reactivity, mi-
gration, and early or late extrusion. Finally, there
is the ever-present problem of infection, either
acute or chronic, resulting from the formation of
a biolm, which may be regarded as consortia of
bacteria organized within an extensive exopolymer
glycocalyx, which confers multiple survival advan-
tages to the component organisms [13].
Alloderm
Alloderm (Life Cell, Branchburg, NJ) is a
commercially available form of allogeneic human
dermis that is available in sheets and can be cut
to the required shape and used as a ller. It is cur-
rently expensive, and the long-term stability of
this construct remains unclear.
Other adjuncts for soft tissue enhancement are
the use of injectable bovine collagen and autolo-
gous and allogeneic human collagen (Autologen
and Dermalogen; Collagenesis, Boston, MA),
both of which are temporary measures usually
requiring reinjection at six monthly intervals to
maintain contour enhancement.
Goretex
Goretex is an alloplastic material composed of
expanded Poly Tetra Fluoro Ethylene (PTFE) and
is available for soft tissue augmentation. It has
been used widely in the face, cheek, lip, and nasal
dorsum for this purpose. Daniel [14,15] is of the
opinion that the widespread use of this material
is potentially hazardous because of its relation to
the long-term risk of infection but that the nasal
dorsum alone may be a privileged site.
Fat injections
Free transplantations of fat date back to the
work of Neuber (1893), Lexer (1910) and Peer in
1950 [16]. Many authors [17,18] have emphasized
the cosmetic advantages of the procedure in that
the same technique can be used to ll soft tissue
defects of the face resulting from trauma, incisions,
and atrophy. The results are heavily dependent on
technique. Multiple injections through separate
ports and overcorrection to account for subsequent
volume loss are the norm. Use of this modality in
heavily scarred or irradiated areas is inadvisable
because of the poor vascularity of the recipient site,
which would not support the persistence of the fat
as a graft.
Bone substitutes
Hydroxyapatite (HA) forms the primary
mineral component of bone. There are two types
of HAs in clinical use: the ceramic type and the
nonceramic type. Until recently, the former was
the only type in clinical use.
Synthetic HA is a homogenous crystalline
solid that is structurally similar to its naturally
occurring bone counterpart and has a chemical
407D. Narayan, J.A. Persing / Neurosurg Clin N Am 13 (2002) 405410
compositionofCa10(PO4)6(OH)2.HAactsasascaf-
fold for the ingrowth of new bone. These are parti-
cularly important compounds in view of the fact
that they probably have the most biocompatible
calcium-phosphate stoichiometry [19,20]. Three of
the synthetic HA compounds that we have used
in practice are Bone Source (LeibingerStryker
Howmedica,Kalamazoo,MI),Norian (Cupertino,
CA) and Mimix (Lorenz, Jacksonville, FL). Bone
Source, which is supplied as a powder, is mixed
in an aseptic fashion with water to form a putty-
like substance that hardens in approximately 15
minutes. Complete hardening occurs over a period
of 4 to 6 hours, however, which can be a liability
in terms of displacement.
Norian, which is a combination of mono-
calcium-monohydrate, a-tricalcium phosphate,calcium carbonate, and sodium phosphate [19,20],
shares a number of common features with Bone
Source but has the purported advantage of solidify-
ing on wet surfaces.
These substances have proved useful in the
treatment of small cranial defects like burr holes
and defects up to 3 cm in diameter.
Computer-aided design/computer-aided machined
production of implants
The availability of three-dimensional represen-
tation of CT data has allowed the transformation
of craniofacial images into solid models. Such
models [21] are produced directly from CT data
interfaced with a numerically controlled milling
device either by sculpting a mold into which a resin
is poured to form the anatomic model or by direct
milling of the model in positive [21]. Accuracy in
conformity with actual anatomy to a resolution
of 0.4 mm is available. An additional advantage
is the preplacement of drill holes for xation to
the skeleton. The computer-aided design/com-
puter-aided machined (CAD/CAM) process cir-
cumvents the need to contour the implant or the
prosthetic material on the table and may provide
a superior cosmetic result with minimal use of
operating room time. In our unit, we have used
this modality with satisfactory results. Conversely,
designing these constructs is expensive and takes
time. This must be contrasted with methylmetha-
crylate, which possesses the advantages of ready
availability, strength, predictable shape, and low
cost but requires exposure to fumes, possible car-
diac arrhythmias, and results in an exothermic
reaction during the process of setting.
Recent advances: cosmetic implications
Minimally invasive surgery
The reverberations of the laparoscopic revolu-
tion have been felt as far aeld as in craniofacial
surgery. Endoscopic techniques have been de-
scribed for the relief of sagittal synostosis [22], for
the harvest of sural nerves [23] and muscles for
free aps [21], and, more recently, for cranial base
surgery and xation of facial fractures. The com-
mon theme is that smaller incisions yield better
cosmesis, shortened recovery times, and, possibly,
fewerwoundcomplications.Balancingtheseadvan-
tages is the downside of increased operative time,
because these procedures have a steep learning
curve. These techniques are not yet universally
accepted nor have their advantages been fully
documented.
Orthotic devices
It may seem strange to include orthotic devices
to shape skulls under the category of recent ad-
vances, when the principles underlying these de-
vices have been known for centuries. Nevertheless,
these devices have enjoyed a resurgence in the wake
of the recent increase in children with deforma-
tional plagiocephaly that resulted from an Amer-
ican Academy of Pediatrics recommendation of
supine positioning for children so as to reduce the
likelihood of the sudden infant death syndrome
[24]. Application of these devices has helped in re-
molding the skull. These devices have also been
tried in conjunction with a limited form of cranio-
plasty (usually linear craniectomies),with the thought
being that the combination of these two modalities
may achieve the same result as the more complete
surgical interventions. This is still being evaluated.
Resorbable plates
The use of resorbable plates in the xation
of the craniofacial skeleton represents a major
advance in the eld, particularly in the pediatric
age group. The advantages are inherent in the
biodegradability of the product in that concerns
about long-term visibility of the plates in thin-
skinned individuals, malpositioned implants, or
the eects of intracranial migration are mitigated.
The plates are generally thicker than their metal
counterparts and are thus more palpable. In gen-
eral, the strength of these plates does not allow
them to be used for high-stress sites like the adult
mandible, but that scenario is bound to change
in the coming years.
408 D. Narayan, J.A. Persing / Neurosurg Clin N Am 13 (2002) 405410
The rst bioabsorbable xation system for the
craniofacial skeleton approved by the US Food
and Drug Administration was the Lorenz Lacto-
sorb system [25,26]. The material used, Lactosorb,
is a copolymer of L-lactic acid (which is slowly
absorbed, thus providing strength) and glycolic
acid (rapidly absorbed) in a 82:18 ratio. Because
it is substantially amorphous, this material has
marked advantages in terms of long-term stability
and degradation compared with the implants made
out of the pure forms of its component chemi-
cals. Clinical complications, such as pronounced
brous encapsulation, sterile abscess and sinus for-
mation, and bone osteolysis, have been reported
for the homopolymers. One of the few studies
showing a reaction to a copolymer(sinus forma-
tion) involved polyglactin 910, a copolymer with
an almost inverse ratio of polylactic acid and
polygalactic acid compared with Lactosorb. In
vivo, the material has been histologically demon-
strated to be eliminated by approximately 1 year
[25,26]. Another bioabsorbable product, Macro-
Pore (Macropore Biosurgery, San Diego, CA)
implants are manufactured from medical grade
100% amorphous 70:30 poly(L-lactide-co-D,L-
lactide). This is produced from a mixture of 70%
L-lactide and 30% DL-lactide, which retains
approximately 70% of its initial strength after 9
months and approximately 50% after 12 months,
converts into carbon dioxide and water by the
process of bulk hydrolysis, and resorbs completely
in approximately 18 to 36 months.
The use of bioabsorbable materials has now
extended to the construction of distraction devices.
We have used resorbable plates for xation of the
pediatric craniofacial skeleton over the last 4 years,
and the results are comparable to those using the
equivalent metal xation devices.
Distraction osteogenesis
Distraction osteogenesis was introduced into
clinical practice by Ilizarov in 1951 [27]. Experi-
mental expansion of the craniofacial skeleton was
demonstrated in a rabbit model by Persing and
colleagues [28,29]. The advantage of this technique
is that bone and soft tissue may be gradually elon-
gated, allowing simpler operative techniques to be
employed. It avoids dead space and decreases the
risk of infection by the reduced rate of change.
The process allows accommodation of soft tissue
to occur.
This feature is desirable, especially in patients
with Ventriculo-Peritoneal (V-P) shunts and those
undergoing monoblock midface advancement.
The technique also has the advantage of avoiding
donor defects for bone grafts.
A preliminary communication on the appli-
cation of this technique to distract the mandible
was made in 1992 [30]. The eld has since ex-
ploded, with distraction being applied to a variety
of cranial substructures, such as the maxilla, mid-
face, and orbit [31]. Clinical results have ranged
from fair to excellent in terms of the cosmetic
results obtained.
Manipulation of wound healing
The pharmacologic manipulation of wounds
to expedite healing has been a long-sought goal.
There has been progress on this front, with studies
reporting accelerated healing with the use of bro-
blast growth factor (bFGF) [32] and recombinant
platelet-derived growth factor (rPDGF) [33]. The
latter is becoming increasingly popular in the treat-
ment of diabetic wounds of the lower extremities,
and o-label indications, such as use in decubiti,
show promise. Although wounds in the craniofa-
cial region are unlikely to need this supplement,
there may be specic scenarios where this adjunct
may be helpful.
Vacuum-assisted wound closure
A recent addition to the plastic surgeons arma-
mentarium is the vacuum-assisted wound closure
device (VAC; Kinetic Concepts, San Antonio,
TX) [21,34]. The premise of this device is that the
constant application of subatmospheric pressure
applied through the medium of medical-grade pol-
yurethane foam (400600-lm pore size) to chronicnonhealing wounds results in a substantial wound
contraction and increase in wound pliability, prod-
ucing wound healing in many recalcitrant cases.
Anecdotally, we have used this device for certain
complex wounds of the torso and lower limb with
good results. It is conceivable that this device
can be applied to carefully chosen complex scalp
wounds to accelerate the healing process.
To summarize, addressing cosmetic concerns
that might initially seem supercial or trivial has
a signicant impact on the functional well-being
of the patient. Coordination of speciality interests
contributes to the nal result.
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[2] Farnworth TK, Beals SP, Manwaring KH, et al.
Comparison of skin necrosis in rats using a new
microneedle cautery, standard size needle cautery,
and the Shaw hemostatic scalpel. Ann Plast Surg
1993;31:1647.
[3] Keenan KM, Rodeheaver GT, Kenney JG, Edlich
RF. Surgical cautery revisited. Am J Surg 1984;
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[4] Orticochea M. New three ap scalp reconstruction
technique. Br J Plast Surg 1967;20:15971.
[5] Orticochea M. Four ap scalp reconstruction
technique. Br J Plast Surg 1971;24:1848.
[6] Juri J. Use of parieto-occipital aps in the surgical
treatment of baldness. Plast Reconstr Surg 1975;55:
45660.
[7] Juri J, Juri C. Aesthetic aspects of reconstructive
scalp surgery. Clin Plast Surg 1981;8:24354.
[8] Finseth F, Cutting C. An experimental neuro-
vascular island ap for the study of the delay
phenomenon. Plast Reconstr Surg 1978;61:41220.
[9] Argenta L, Watanabe MJ, Grabb CH. The use of
tissue expansion in head and neck reconstruction.
Ann Plast Surg 1982;11:317.
[10] Cheng K, Zhou S, Jiang K, et al. Microsurgical
replantation of the avulsed scalp. Report of 20
cases. Plast Reconstr Surg 1996;97:110916.
[11] Janecka IP. Classication of facial translocation
approach to the skull base. Otolaryngol Head Neck
Surg 1995;112:57985.
[12] Janecka IP, Sen CH, Sekhar LN, et al. Facial
translocation: a new approach to the cranial base.
Otolaryngol Head Neck Surg 1990;103:4139.
[13] Costerton JW, Cheng KJ, Geesy KG, et al. Bacterial
biolms in nature and disease. Ann Rev Microbiol
1987;41:43564.
[14] Daniel RK. (Discussion) The use of Gore-Tex for
nasal augmentation: a retrospective analysis of 106
patients. Plast Reconstr Surg 1994;94:24950.
[15] Daniel RK. The Gore-Texed patient. Plast Reconstr
Surg 1995;95:1336.
[16] Peer LA. Loss of weight and volume in human fat
grafts: with postulation of a cell survival theory.
Plast Reconstr Surg 1950;5:21730.
[17] Guerrerosantos J. Autologous fat grafting for body
contouring. Clin Plast Surg 1996;23:61931.
[18] Toledo S. Syringe liposculpture. Clin Plast Surg
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[19] Burgess EA, Mayer MH, Hollinger J. Bone grafting
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[21] White DN. CT scans, multidimensional refor-
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Company; 1991. p. 95107.
[22] Barone CM, Jimenez DF. Endoscopic craniec-
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[23] Koh KS, Park S. Endoscopic harvest of sural nerve
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[24] Anonymous. American Academy of Pediatrics
(AAP) task force on infant positioning and SIDS.
Pediatrics 1992;89:11206.
[25] Pietrzak WS, Verstynen ML, Sarver DR. Bioab-
sorbable xation devices: status for the craniomax-
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[26] Rubin PJ, Yaremchuk MJ. Complications and
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410 D. Narayan, J.A. Persing / Neurosurg Clin N Am 13 (2002) 405410
Hair sparing techniques and scalp ap designJoseph C. Camarata, DMD, MD, Peter T.H. Wang, DMD, MD*
Division of Plastic Surgery, University of Texas Health Science Center at San Antonio,
7703 Floyd Curl Drive, Mail Code 7844, San Antonio, TX 78229-3900, USA
There are numerous surgical scalp exposures
to the cranium. Traditional straight-line incisions
often leave visible scars. Recent advances in under-
standing the scalp physiology and its blood supply
enable the surgeon to design safe scalp aps and
obtain a better cosmetic result.
Scalp anatomy
The scalp is a specialized tissue consisting
of ve layers: skin, subcutaneous tissue, galeal
aponeurosis, loose areolar tissue, and pericranium
(SCALP) (Fig. 1). Vessels and nerves enter the
scalp in a centripetal direction and travel within
the subcutaneous and galeal layers. The main
blood supply to the scalp is from ve arteries
on each side: supratrochlear, supraorbital, super-
cial temporal, posterior auricular, and occipital.
The supercial temporal artery has anterior and
parietal branches. These vessels are intercon-
nected with some anastomosis across the midline
(Fig. 2). When designing the scalp aps, the major
axial vessels should be incorporated within the
base of the ap. Branches of the rst division of
the trigeminal nerve provide the sensory inner-
vationof the scalp anteriorly. The occipital branches
of the second cervical nerve supply the posterior
scalp. Transection of the nerve during the scalp
incision often results in annoying postoperative
dysesthesia. The frontalis muscle of the galea is in-
nervated by the frontal branch of the facial nerve.
Care must be taken when raising a bicoronal ap in
the temporal region, because the frontal branch
runs on the deep surface of the temporoparietal
fascia (an extension of the galea in the temporal re-
gion) as it crosses the zygomatic arch.
Hair
The hair bulb extends into the subcutaneous
plane. There are two groups of stem cells that ulti-
mately are responsible for hair growth [1]. The low
stem cells are located in the bulb of the shaft. The
second group of high stem cells is located in the
sebaceous units, which are often found in the mid-
skin level (Fig. 3). The hair shafts are supplied by
the subcutaneous vascular plexus. The direction
of hair growth is established early in infancy. In
the temporal and occipital region, the hair tends
to fall downward. At the superior scalp, the hair
grows anterior and oblique. The hair retains its
orientation even after the scalp is repositioned.
Bicoronal incision
The bicoronal incision oers an excellent ex-
posure to the entire cranium. The location of the
incision varies depending on the emphasis of the
surgical region [2]. Ideally, the incision is placed
in the middle to posterior to the equator to hide
the incision. If the exposure is for craniofacial sur-
gery, however, the incision may be placed more
anteriorly such that there is less scalp to turn over,
allowing easier access to the facial bones. If neces-
sary, preauricular extensions are performed for
additional facial skeleton exposure. Postauricular
extensions have been reported for better cosmetic
appearance [3].
Straight line versus zigzag
Although a straight-line incision is simple and
fast to incise and close, the resultant linear scar is
often visible, especially in the temporal region.
Not infrequently, as the hair gets wet, such as
when coming out of the swimming pool or shower,* Corresponding author.
E-mail address: wangp@uthscsa.edu (P.T.H. Wang).
1042-3680/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved.PII: S 1 0 4 2 - 3 6 8 0 ( 0 2 ) 0 0 0 2 9 - 3
Neurosurg Clin N Am 13 (2002) 411419
the hair in the temporal region parts to either side
of the scar, making it more obvious [4]. The reason
why this happens is because hair in the temporal
region grows directly downward. The straight-line
scar placed parallel to the direction of hair growth
in the temporal region is not hidden by the hair
drape. Furthermore, as the scar widens, the hair-
bearing scalp moves farther away, increasing the
visibility of the scar (Figs. 4 and 5).
Ideally, the incision should be placed perpen-
dicular to the direction of the fall line of the hair.
The hair provides maximum coverage to the scar,
even if the scar widens in the future. In general,
the direction of hair growth is downward in the
temporal, parietal, and occipital scalp. In the cen-
tral region, the course of hair growth is more var-
iable, mostly in the anterior direction or sideways.
As a result, in designing the coronal incision, the
zigzag pattern is placed in the temporal region to
decrease the potential scar visibility (Fig. 6) [46].
In the central scalp, the zigzag pattern can be con-
tinued between the two temporal fusion lines or
can be modied with a gentle curve (widows peak)
(Fig. 7). Starting above the helical root, the rst
Fig. 1. Layers of the scalp. (From Dingman, Argenta. The surgical repair of traumatic defects of the scalp. Clin Plas
Surg 1982;9:133; with permission.)
Fig. 2. Vascular supply of the scalp. (FromDingman, Argenta. The surgical repair of traumatic defects of the scalp. Clin
Plas Surg 1982;9:133; with permission.)
412 J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419
triangle is directed posteriorly. The subsequent tri-
angles moving superiorly can have equal angle
between the limbs and length of the limbs, or
the angle can be sharper inferiorly and gradually
widen superiorly. The sharper angles allow more
horizontal limbs in the zigzag pattern [5]. Creating
the zigzag pattern using a preformed template
has also been described as facilitating the incision
design [5]. A sinusoidal pattern employing prin-
ciples similar to those of the zigzag incision, with
rounded transitions between limbs, can also be
used (Fig. 8).
The disadvantage of the zigzag incision is that
it takes longer to make and longer to close at
the end. The zigzag pattern also makes it harder
to retain the Raney clips on the scalp edge. A
postauricular incision has been described as an
extension of the coronal incision. Although this
method can adequately expose the anterior cranio-
facial skeleton, it is probably more suitable for
the posterior half of the calvaria [3].
Minimizing scar width and scalp elevation
The scar width is a result of alopecia adjacent to
the incision or widening of the incisional scar. To
preserve the maximum number of hair follicles,
the incision is made parallel to the shaft of the hair.
The beveled incision preserves the largest number
of hair roots, which have the ability for future hair
growth (Fig. 9). If one is uncertain of the direction
of the hair shaft, it would be better to incise per-
pendicular to the scalp rather than risking beveling
in the wrong direction, which can lead to addi-
tional hair loss adjacent to the scar. Another con-
sideration is to minimize the thermal damage from
the electrocautery to the hair bulbs that extend
into the subcutaneous plane. Both the bipolar tip
and Colorado needle provide pinpoint cauteriza-
tion compared with the blade cautery; nonetheless,
Fig. 3. Hair bulb with low stem cells in the bulb shaft
and high stem cells in the sebaceous units. (From Seery,
GE. Scalp surgery: anatomical and biomedical consid-
erations. Dermatologic Surgery 2001;27(9):82734; with
permission.)
Fig. 4. A 14-year-old girl underwent a straight-line bicoronal incision for craniofacial reconstruction. The visible
straight-line vertical scar is dicult to camouage by means of the temporal hair drape.
413J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419
Fig. 5. A male patient had a straight-line hairline incision for a craniotomy to expose massive craniofacial trauma.
Fig. 6. (A) Zigzag design of bicoronal incision in the temporal scalp. (B) The zigzag design continued across the entire
scalp. (C) Postoperative view.
414 J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419
the high temperature conduction can damage the
nearby hair bulb [4,7]. There are several helpful
methods to control the bleeding scalp. The scalp
can be inltrated with local anesthetic containing
epinephrine before incision, which results in vaso-
constriction. Hemostasis can also be achieved by
placing parallel locking sutures to the incision
before making the incision. Raney clips provide
the conventional method of controlling the scalp
bleeding; however, these clips are cumbersome
and frequently dislodge. In addition, prolonged
clamping by Raney clips on the scalp edge, as in a
long operation, may result in ischemia of the hair
follicles and subsequent scar alopecia.
Scalp closure
To minimize the widening of the scar itself, the
scalp ap closure should be performed without
tension. Some surgeons have shown that place-
ment of wide relaxation sutures at 2- to 3-cm in-
tervals with supercial (epidermal) suturing has
Fig. 7. (A) Zigzag design of bicoronal incision in the temporal scalp. (B) The zigzag pattern was changed to a gentle
curve in the central scalp (widows peak). (C) Postoperative view. Note that the zigzag incision pattern is well hidden by
the fall line of the hair in the temporal region.
415J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419
resulted in minimal linear scar formation [8]. This
method of relaxation sutures is thought to avoid
tension in the upper stem cell sebaceous units, to
allow hair regeneration within the incision, and,
in some instances, to avoid temporary hair loss.
The strength layer, the galea, must be reapproxi-
mated to minimize the tension on the skin closure.
Long-lasting absorbable sutures such as PDS or
Vicryl are generally used. The choice of suture on
the skin layer depends on surgeons preference.
For children, resorbable sutures such as chromic
gut or Monocryl are preferred to avoid the process
of suture removal. Buried long-lasting sutures like
PDS may provide additional internal retention to
the closure. In adults, Prolene suture or even skin
staples can be used for skin closure, followed by
removal in 7 to 10 days. The method of suturing
the skin layer probablymakes little dierence if per-
formed without tension. Although running vertical
mattress sutures evert the skin edge, running simple
sutures are much faster and likely to produce the
same cosmetic results. It is probably a good idea
to avoid deep skin sutures so as not to damage
the deep hair follicles. Another method in the pre-
vention and treatment of wide scars is beveling
wedge excision and placement of double relaxation
sutures [8]. The rationale is to allow the preserved
hair root to grow through the incision scar even-
tually. In summary, by adhering to the principles
of tensionless closure and preservation of hair fol-
licles, scar width and alopecia can be minimized.
To shave or not to shave
Hair shaving has long been a standard practice
in the surgical approach to the cranium. Although
this certainly facilitates preoperative markings and
avoids working within the hair, there is no evi-
dence that shaving prevents wound infections. In
fact, it may lead to higher rates of wound infection
as a result of epidermal injury from shaving [9].
Shaving the scalp before surgery has the benets
of better visualization of underlying cranial de-
fects, facilitation of markings, and avoidance of
the potential annoyance of working within the
hair. One must also take into consideration
the psychologic impact this has on patients and the
potential delay in rehabilitation. From an esthetic
standpoint, sparing the hair with no shaving or
minimal shaving along the incision signicantly
improves the immediate postoperative appear-
ance. There is no typical stigma of baldness from
a neurosurgical procedure; thus, the psychologic
Fig. 8. A sinusoid pattern is used in this baby for recon-
structive exposure for unicoronal synostosis.
Fig. 9. Beveled incision parallel with hair follicles for
preservation of hair roots. (From Ellis E III, Zide M.
Surgical approaches to the facial skeleton. Lippincott
Williams and Wilkins; 1995 [chapter 6].)
416 J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419
aspect is also improved, especially for female
patients. Surgeons are often annoyed by the hair
in the operative eld, however. Hair of moderate
length can be braided into separate bundles
(Fig. 10), whereas shorter hair can be isolated with
towels covering the hair and xed with staples (Fig.
11). In addition, antibiotic ointment or Surgilube
(E. Fougera & Co., Melville, NY) temporarily
parts the hair from the surgical eld, which is help-
ful during the closure of the scalp incision. A deci-
sion to shave the scalp before surgery should be
based on these advantages and not to protect
against wound infection, because shaving the scalp
may lead to a higher risk of postoperative wound
infection.
Temporal hollowing
Temporal hollowing is a not infrequently seen
cosmetic complication after scalp incision in the
temporal region. The reason may be associated
with temporalis muscle atrophy or failure of resus-
pension of the temporalis muscle. The temporalis
muscle is handled in a couple of ways during the
surgical approach. The muscle can be left with
the scalp ap, and a subperiosteal dissection is
performed. This probably maintains a better
blood supply and minimizes temporal atrophy or
hollowing. Alternatively, the muscle is elevated as
a separate ap from the scalp ap. On closure, it is
important to resuspend the muscle to its original
position or even to advance the muscle ap an-
terior to the orbital rim. Failure to reattach the
muscle or injury to the blood supply results in
muscle retraction, atrophy, and temporal hollow-
ing. Invariably, some degree of muscle atrophy
occurs once the muscle has been elevated. Another
article in this issue discusses temporal hollowing in
further detail.
Local scalp aps and management
of irradiated scalp
Unlike other areas of the skin, the scalp is less
yielding in its elasticity as an advancement ap.
Consequently, small wounds on the scalp require
a larger than expected ap design to obtain ten-
sionless closure. Of the many scalp aps used for
wound coverage, there are a couple of aps that
have a broad ap base and good blood supply.
The rotation ap has been the workhorse for
scalp wound closure. For small- to moderate-sized
wounds, the rotation ap may allow wound cover-
age and primary closure. Larger wounds may re-
quire back-grafting of the donor site with a skin
graft. Ideally, the ap should be based on a major
axial artery (Fig. 12). Larger scalp wounds can be
covered by a bipedicle scalp ap (visor ap), with
back-grafting of the donor site. When back-graft-
ing is anticipated, the periosteum must be left
intact for the skin graft to heal. Alternatively, the
galea or temporoparietal fascia can be dissected
under the subfollicular layer of the scalp. This
layer alone or combined with the periosteum is
elevated as a rotation ap or bipedicle ap to close
small defects, followed by a skin graft. The appli-
cation of the galeal ap is limited to small wounds
because of its thin fascia, random blood supply,
and tedious dissection. Under elective circumstan-
ces, tissue expanders are helpful to recruit and gain
additional scalp tissue.
Fig. 10. Separate bundles of hair braided with needle
driver and small elastic bands. (From Worthen. Scalp
aps and the rotation forehead ap. In: Strauch B,
Vasconez L, Hall-Findlay EJ, editors. Grabbs Encyclo-
pedia of Flaps. 2nd Edition. Boston: Little, Brown and
Co.; 1990.)
Fig. 11. Only the surgical strip is shaved. The anterior
hair is covered by a surgical towel stapled to the scalp, as
is the posterior scalp.
417J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419
Radiation to the scalp after tumor resection
causes local tissue damage, which may lead to
wound breakdown at the incision line. Further-
more, radiation complicates wound healing if
re-resection becomes necessary through the same
incision. If the wound breaks down at the incision
line, it must be excised and covered with a well-
vascularized ap under no tension. If a U-shaped
(horseshoe) ap was the original incision, a con-
tralateral rotation ap is a good option for wound
coverage. If a bicoronal incision was used for
exposure, the bipedicle ap with back-grafting
has been described to cover the incision wound
breakdown. Furthermore, it has been suggested
that in the initial preoperative planning, if radia-
tion and reoperation are anticipated, a linear inci-
sion (bicoronal ap) rather than the U- shaped
incision should be designed parallel to and not to
sever the major axial artery. A bicoronal incision
oers excellent cranial exposure and is a good op-
tion in such a situation. The supercial temporal
artery should be spared in this approach. Ulti-
mately, the design and placement of the incision
should compromise the vascularity and postopera-
tive wound healing to the least extent possible
[10]. Scalp reconstruction for repeated failures
using local aps to repair irradiated wounds re-
quires free tissue transfer.
Summary
Individualizing each patient in deciding on ap
selection, ap design, hair sparing or shaving, and
method of closure ensures proper treatment out-
come with the goal of achieving a good cosmetic
result.
Fig. 12. Scalp advancement ap based on axial blood supply with back-grafting. (From Baker SR, Swanson NA. Local
aps in facial reconstruction. Philadelphia: Mosby Yearbook, Inc.; 1994 [chapter 22].)
418 J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419
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[3] Posnick JC, Godstein JA, Clokie C. Advantages of
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[4] Munro IR, Fearon JA. The coronal incision
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[5] Fisher DM, Goldman BE, Mlakar JM. Template
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[6] Frodel JL, Mabrie D. Optimal elective scalp inci-
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[7] Papay FA, Stein J, Luciano M, Zins JE. The micro-
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[8] Burm JS, Oh SJ. Prevention and treatment of wide
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[9] Siddique MS, Matai V, Sutclie JC. The preoper-
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[10] Nair S,GiannakopoulosG,GranickM, SolomonM,
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419J.C. Camarata, P.T.H. Wang / Neurosurg Clin N Am 13 (2002) 411419
Cosmetic considerations in cranial base surgeryChristopher A. Bogaev, MD
Division of Neurosurgery, University of Texas Health Science Center at San Antonio,
4410 Medical Drive, Suite 610, San Antonio, TX 78229-3798, USA
Recent advances in the surgical techniques for
the resection of cranial base tumors have allowed
for improved degrees of tumor resection, func-
tional outcomes, and esthetic results. If the resec-
tion and functional results are not compromised
by procedures providing excellent cosmetic out-
comes, there is no reason to ignore or compromise
the aesthetic aspect with regard to technical exe-
cution and planning. A thorough assessment of the
patients preoperative decits and tumor anatomy
and a working knowledge of the available cranial
base approaches and their combinations permit
the surgeon to design an approach that allows
for optimal tumor resection with the best possible
cosmetic result. Presented in this article is a discus-
sion of the indications of the various cranial base
approaches available and their combinations, with
an emphasis on the skin incision used and the sur-
gical techniques that facilitate a favorable aesthetic
outcome.
Although a large armamentarium of craniofa-
cial approaches exists to treat cranial base tumors,
progressive emphasis is more recently being
placed on those with superior esthetic outcomes.
Many of the cranial base approaches or combina-
tions of them are successful at providing the neces-
sary exposure for successful tumor resection. No
onewouldargue that this is theprimarygoalof these
procedures. Coupledwith degree of resection, func-
tional outcome and quality-of-life issues must be
factored into the surgical decision-making process.
As these procedures have evolved, so have the
means to meet these goals of adequate resection
with good functional and cosmetic results. If the
resection and functional preservation are not
compromised by procedures providing excellent
esthetic outcomes, there is no reason to ignore or
compromise the cosmetic aspect with regard to
technical execution and planning. The cosmetic
result is an important issue in the patients quality
of life and reintegration into society.
Transfacial versus alternative approaches
to the skull base
Visible scars from facial incisions are a promi-
nent consideration for many patients, particularly
the young ones [1]. This is especially important in
the setting of radiation therapy or other proces-
ses that may interfere with wound healing or ex-
acerbate scar formation. Because of the variety
of available craniofacial exposures to the skull
base, a combination of approaches is usually avail-
able that can provide the required exposure with-
out a facial incision. If the skin or underlying
soft tissues are involved with tumor, an en bloc
resection, including the skin, may be required [1].
In choosing a surgical approach for a cranial
base tumor, the initial determination is whether
an intradural or extradural approach is needed.
An approach or combination of approaches can
then be selected from one of these sets depending
on the location, extension, and decits caused by
the tumor. Intradural cranial base approaches
include frontal or frontotemporal craniotomy with
orbital or extended orbital osteotomy, frontotem-
poral craniotomywithorbitozygomatic osteotomy,
presigmoid petrosal approach and its variations,
retrosigmoid approach, and extreme lateral partial
transcondylar approach. Extradural cranial base
approaches include frontotemporal craniotomy
with orbitozygomatic osteotomy, subtemporal/
infratemporal approach, extended subfrontal
transbasal approach, extreme lateral transcondylarE-mail address: CAB@neuroassocsa.com
(C.A. Bogaev).
1042-3680/02/$ - see front matter 2002, Elsevier Science (USA). All rights reserved.PII: S 1 0 4 2 - 3 6 8 0 ( 0 2 ) 0 0 0 2 7 - X
Neurosurg Clin N Am 13 (2002) 421441
approach, transsphenoidal approach, and midface
degloving with Le Fort I osteotomy.
Intradural cranial base approaches
Frontotemporal craniotomy with
orbital osteotomy
The increased exposure provided by the addi-
tion of an orbital osteotomy to a pterional, frontal,
or frontotemporal craniotomy is most useful for
lesions of the anterior fossa, orbit, orbital apex,
anterior communicating artery complex, parasel-
lar region, retrosellar region, cavernous sinus, ten-
torial notch, anterior middle fossa, and olfactory
groove [27].
A unilateral question markshaped incision is
most commonly used. The incision is made well
behind the hairline (except at its anterior tip,
which extends to the anterior border of the hair-
line) so as to preserve hair anterior to the inci-
sion and to circumvent the bulk of the temporalis
muscle (Figs. 1 and 2). This prevents cutting the
muscle and facilitates its re-elevation at the time
of closure. Factors thought to contribute to
temporalis atrophy include denervation, devas-
cularization, disuse, or muscle ber injury [8]. Notcutting the temporalis muscle, at least through its
thick portion, helps to prevent devascularization
or denervation of the separated portion, and care-
ful elevation of the muscle helps to prevent muscle
ber injury. To eliminate the last risk factor for
atrophy, the temporalis muscle is carefully reat-
tached to its anatomic origin as closely as possible
at the time of wound closure so as to re-establish
its anatomic and functional integrity. One method
of accomplishing this involves leaving a cu of
muscle or fascia attached along the superior tem-
poral line as described by Spetzler and Lee [9],
allowing the muscle to be sutured back to its origin
at the time of wound closure. Another method is to
elevate the temporalis muscle entirely and resecure
it at the time of closure with sutures to multiple
oblique holes drilled along the superior temporal
line. This latter method carries the advantage of
not cutting the temporalis muscle at all. Excellent
results have been attained with both techniques.
Aside from temporalis muscle issues, incisions
are made well behind the hairline (preferably, at
least 3 cm) for optimal cosmetic results. Incisions
just behind the hairline are cosmetically inferior
[10] because of the alteration in hair patterns,
making the incision signicantly more obvious
both short and long term. An incision along the
hairline is signicantly less noticeable than one
just behind it.
Fig. 1. Anterolateral view of question mark incision
used for a frontotemporal craniotomy with an orbital or
orbitozygomatic osteotomy. Note the lower pole of the
incision following the pretragal skin crease.
Fig. 2. Lateral view of question mark incision used for a
frontotemporal craniotomy with an orbital or orbitozy-
gomatic osteotomy. Note the lower pole of the incision
following the pretragal skin crease.
422 C.A. Bogaev / Neurosurg Clin N Am 13 (2002) 421441
In patients with a receding hairline or in bald
patients, a bicoronal incision is signicantly less
noticeable than a question mark incision (Figs. 3
and 4). If the hairline is high on the forehead, a
question mark incision may provide inadequate
basal frontal exposure unless the incision is ex-
tended onto the forehead, resulting in a subopti-
mal cosmetic result.
The lower end of many of these incisions is
made in the skin crease just anterior to the tragus
(see Figs. 14). This is more cosmetic, because
the incision is hidden in a normal skin crease. It
also avoids injury to the frontotemporal branch
of the facial nerve and supercial temporal artery
[3,11,12].
Once the best incision has been chosen, the hair
is parted along the planned incision line with a
comb after the head has been placed in pins and is
in the operative position. The hair is easier to part
if it is moistened with saline, alcohol, or antibiotic
ointment. Only 0.5 to 1.0 cm of hair is then shaved
on either side of the incision tokeep adhesive drapes
in place and facilitate closure. Even if a small strip
of hair is shaved, sucient re-growth of hair stub-
ble occurs after approximately 2 weeks to allow
the area of the incision to be less noticeable and
blend with the surrounding hair. Patients with lon-
ger hair can hide the small shaved area along the
incision by combing the surrounding hair over it.
Once the scalp is elevated, an interfascial dissec-
tion of the frontotemporal branch of the facial
nerve is performed on the side of the orbital os-
teotomy, and the temporalis muscle is elevated
completely from its origin for reasons previously
described. This also allows the temporalis muscle
to be retracted laterally, keeping it more out of
the way of the focal point of the exposure. With
bicoronal incisions, the contralateral temporalis
muscle and fascia are left undisturbed. A detailed
description of the craniotomy and osteotomy
techniques is provided in the article in this issue
on osteotomy design and execution.
Fig. 3. Anterolateral view of standard bicoronal incision
used for multiple cranial base approaches. Note that the
incision is placed well behind the hairline for cosmetic
reasons as well as to provide a large pericranial graft.
Note the lower pole of the incision following the pre-
tragal skin crease.
Fig. 4. Frontal view from above of standard bicoronal
incision used for multiple cranial base approaches. Note
that the incision is placed well behind the hairline for
cosmetic reasons as well as to provide a large pericranial
graft. Note the lower pole of the incision following the
pretragal skin crease.
423C.A. Bogaev / Neurosurg Clin N Am 13 (2002) 421441
Eyebrow incisions for basal frontal exposure
Signicant controversy exists concerning the
utility, indications, and cosmetic advantages of
the use of eyebrow incisions for frontal or supra-
orbital craniotomies with or without an orbital
osteotomy. Several case series have been reported
describing the ecacy and excellent cosmetic re-
sults for anterior circulation aneurysms and tu-
mors of the anterior cranial fossa and parasellar
region [1315].
For approaches to these regions, bicoro-
nal, pterional, or question mark incisions have
been used traditionally. One of the advantages de-
scribed for the eyebrow incision is improved basal
frontal exposure with reduced brain retraction,
particularly with the use of an orbital osteotomy.
Few would argue that this basal exposure re-
duces brain retraction, but the same bone work
can be performed through an incision behind the
hairline. As discussed earlier, if the hairline is
receding or is suciently far posterior that basal
frontal exposure is limited using a unilateral cur-
vilinear or question mark incision, a bicoronal
incision can be used with no limitation to basal
frontal exposure. Therefore, identical bone work
to that described for the eyebrow incision can also
be performed through incisions behind the hair-
line, making the technical dierences mainly in
the placement of the incision.
Other advantages described for eyebrow inci-
sions are the reduced operative time and the excel-
lent cosmetic results [1315]. This may be a viable
argument because of the reduced length of the
eyebrow incision compared with traditional inci-
sions behind the hairline, particularly a bicoronal
incision. From the cosmetic perspective, some
who use eyebrow incisions place them in the upper
border of the eyebrow but sometimes extend them
into a skin crease or wrinkle in the frontozygo-
matic area beyond the lateral extent of the eye-
brow [13,14]. Furthermore, signicant variability
may exist in the size, thickness, conguration,
and extent of various patients eyebrows, which
may limit exposure unless eyebrow incisions are
extended into neighboring areas of the face. For
this reason, scars may potentially be visible and
are not always hidden by the eyebrow. With re-
gard to the cosmetic signicance of this, John
Diaz Day expressed the sentiments of many cri-
tics of the eyebrow incision when he wrote: The
incision that is made completely within the hair-
line is essentially never seen, in contrast to inci-
sions across any part of the forehead or the lateral
orbit. Even with the most meticulous closure, an
incision line remains that simply is not present
when the incision is made within the hairline
[16]. With regard to the cosmetic results and re-
duced operative time of the eyebrow incision,
Iver A. Langmenwrote: I have used this approach
on selected patients for years, and my impression
is that neither the cosmetic results nor the operat-
ing time are improved as compared with a stand-
ard orbitopterional craniotomy [16].
Flexibility is important, because as with other
techniques, cosmetic results can be dependent on
many factors. According to Perneczky et al [14],
a standard skin incision does not exist for this
approach, because the individual anatomy of a
patient should be respected: Important individual
details of the skin, which may greatly determine
the post-operative cosmetic result and the satisfac-
tion of the patient, such as wrinkles, size and shape
of the eyebrows, frontal hairline, or sidewhiskers,
are also visible during the clinical examination
and may inuence the decision-making for an indi-
vidual approach.
Other disadvantages described for the eyebrow
incision are that it is more dicult to obtain a large
pericranial graft, and one study reported a 6.9%
cerebrospinal uid (CSF) leak rate [15], possibly
because of the increased diculty in repairing
large frontal sinus defects through this incision.
Frontalis weakness has been described as a
temporary sequela to an approach performed
through this incision. Three separate sources
have reported no permanent frontalis weakness,
however [1315]. Perneczky et al [14] attribute
this to the course of the frontotemporal branch
of the facial nerve virtually never crossing this
type of skin incision. The temporary weakness
is usually attributed to retraction.
The average size of a craniotomy performed
through an eyebrow incision has been described
as 25 to 30 mm 15 to 20 mm [14] for endoscope-assisted craniotomies up to an average of 2.5 cm 3.5 cm for the supraorbital microcraniotomy with
an orbital osteotomy [13]. The temporalis muscle is
minimally elevated from the region of the ana-
tomic keyhole, and a single keyhole burr hole is
placed [1315]. If an orbital osteotomy is to be
included, the craniotome has been used to cut
the frontozygomatic process, and the orbital roof
and lateral orbital wall are fractured with osteo-
tomes [13] or a small cutting burr [15]. The cranio-
tomy and orbital osteotomy are removed as a
single piece [13,15]. A detailed discussion of one-
piece versus two-piece orbital osteotomies follows
424 C.A. Bogaev / Neurosurg Clin N Am 13 (2002) 421441
in the article in this issue on osteotomy design and
execution.
In summary, the most signicant dierences
between the eyebrow incision and more traditional
techniques are the cosmetic result, smaller pericra-
nial graft obtainable, more limited exposure, and a
possible reduction in operative time. Supraorbital
craniotomy through an eyebrow incision has been
demonstrated to be a useful approach under the
proper indications, however.
Extended orbital osteotomy
This approach involves a frontal or fronto-
temporal craniotomy with extension across the
midline, with the orbital osteotomy extending
across the midline to include the glabella. This
greatly enhances midline basal frontal exposure
and combines the advantages of a bifrontal and
pterional craniotomy. This approach is also refer-
red to as a one-and-a-half fronto-orbital approach.
It is most appropriate for large neoplasms of
the anterior cranial fossa with extension across
the midline, such as olfactory groove or planum
sphenoidalemeningiomas.Anotable feature of this
approach is that the cribriform plate is not mani-
pulated so that olfaction is potentially spared.
A bicoronal incision is used for this approach
to provide the required exposure across the mid-
line. The incision is placed well behind the hairline
not only for cosmetic reasons but to allow for a
large pericranial graft for the repair of any eth-
moidal or frontal sinus defects (see Figs. 3 and
4). Minimal hair is shaved along the planned inci-
sion line as described earlier. The lower ends of the
incision are placed in the pretragal skin creases
also as described earlier. An interfascial dissection
of the frontotemporal branch of the facial nerve
is performed ipsilaterally, and the temporalis mus-
cle is elevated completely. The craniotomy, osteo-
tomy, and reconstruction are described in detail in
the article in this issue on osteotomy design and
execution.
Frontotemporal craniotomy with
orbitozygomatic osteotomy
The rationale for an orbitozygomatic osteo-
tomy is similar to that for an orbital osteotomy.
The major advantage gained with the orbitozygo-
matic approach is a signicant increase in subtem-
poral exposure [17]. If subtemporal exposure is
not needed, an orbital osteotomy alone is likely
to suce. Similarly, a standard orbitozygomatic
osteotomy is not performed with a frontal cranio-
tomy but only with a frontotemporal or pterional
craniotomy.
A frontotemporal craniotomy with an orbi-
tozygomatic osteotomy is often used for lesions
of the anterior and middle fossae, upper clivus,
parasellar region, interpeduncular fossa, medial
sphenoid wing, clinoidal region, Meckels cave,
tentorial notch, or cavernous sinus or for basilar
tip aneurysms [12,1823]. A more general indica-
tion is for lesions suitable for an orbital osteotomy
with the need for additional basal exposure to the
middle fossa (subtemporal) [17], tentorial notch,
or upper clivus [20].
Either a unilateral question mark (see Figs. 1
and 2) or a bicoronal incision (see Figs. 3 and 4)
can be used, with the incision being placed well
behind the hairline with minimal hair shaved as
described earlier. A bicoronal incision is prefer-
red if the patient has a receding hairline or a suf-
ciently posterior hairline such that inadequate
exposure is provided without extending the inci-
sion onto the forehead. Crossing the anterior end
of a question mark incision to the opposite mid-
pupillary line (Fig. 5) is an option [22] but does
not produce the additional exposure provided by
a bicoronal incision and may still provide insu-
cient exposure in patients with a receding hairline.
The added eort of performing a bicoronal inci-
sion is more than compensated for by the reduced
eort of performing the orbitozygomatic osteo-
tomy with improved exposure. In either case, the
inferior end of the incision extends into the pre-
tragal skin crease. An interfascial dissection of the
frontotemporal branch of the facial nerve is per-
formed, and the temporalis muscle is completely
elevated as described earlier. A detailed descrip-
tion of the craniotomy, osteotomy, and recon-
struction is provided in the article in this issue on
osteotomy design and execution.
Presigmoid petr