TECHNICAL STRATEGY
The Posterior Coronal Incision Sabrina Nicole Pavri, MD, MBA,* Eric Arnaud, MD,† Dominique Renier, MD, PhD,† and John A. Persing, MD* Background: The coronal incision is a standard surgical approach in craniofacial surgery. It has undergone many modifications during the years in an attempt to optimize the esthetic appearance of the scar, including the sawtooth “stealth incision” and the sinusoidal incision. Methods: We describe an alternative coronal approach extending posteriorly from the postauricular region over the occiput, resulting in an axial scar. Results and Discussion: The posterior coronal incision provides equivalent exposure of the craniofacial skeleton while placing the scar in an esthetically optimal location that is much more likely to be camouflaged by hair, especially in patients with thinning hair or male-pattern baldness. It avoids a vertical temporal scar that is prone to widening and also allows the incision to be placed remotely from any neurosurgical hardware in the frontotemporal region. It may be used in craniofacial or neurosurgical procedures requiring access to the posterior or anterior cranial vaults or the upper craniofacial skeleton down to the maxillary alveolar rim. Key Words: Posterior, axial, coronal incision, craniosynostosis, craniofacial surgery (J Craniofac Surg 2015;26: 00–00)
T
he coronal incision has been a standard approach for surgical exposure of the craniofacial skeleton for many years, allowing easy access to the anterior and posterior cranial vaults and the facial skeleton above the level of the maxillary alveolar rim. Although technically camouflaged in the hair, modifications of the straight coronal incision extending across the vertex of the skull have been developed because of the esthetically unappealing widening of the scar, especially in the more visible temporal region, and its prominence when the hair is wet or extremely short.
MATERIALS AND METHODS Here, we describe a modification of the coronal incision extending from just superior and posterior to the root of the helix, across the occiput, to the contralateral helical root (Figs. 1–3). The blood supply to the scalp flap is through the posterior branches of the ascending superficial temporal artery, which anastamose with branches of the posterior auricular and occipital arteries. Care is From the *Section of Plastic Surgery, Yale University School of Medicine, New Haven, Connecticut; and †Craniofacial Unit, Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, Paris, France. Received July 20, 2014. Accepted for publication October 9, 2014. Address correspondence and reprint requests to John A. Persing, MD, Section of Plastic Surgery, Yale University School of Medicine, 330 Cedar Street, PO Box 208041, New Haven, CT, 06520-8041; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001374
taken not to position the incision too superiorly to preserve the parietal branch of the superficial temporal artery, because the occipital and posterior auricular artery branches are cut during the incision (Fig. 1). The dissection proceeds in the same relatively avascular subgaleal plane as the traditional coronal incision, and the additional dissection required adds minimal time to the procedure (Figs. 2, 3).
RESULTS This technique places the incision line away from the hair part and in a location less likely to be affected by the hair recession of male pattern baldness. In balding patients (Figs. 4–6), the scar in this technique is placed in the region of the occipital scalp, in an area that usually remains hair bearing even in balding patients. The scar is well camouflaged due to the orientation of the hair follicles perpendicular to the incision, and we avoid a vertical temporal scar that is prone to widening and more poorly camouflaged, as it lies parallel to the temporal hair follicles.
DISCUSSION The original bitemporal coronal incision extended in a straight line from the root of the helix over the vertex of the skull to the contralateral helical root and could be extended inferiorly as a preauricular incision depending of the exposure required. The technique usually involved preoperative shaving of either the entire head or, alternatively, a small 1- to 2-cm strip in the area of the planned incision.1 This incision transected the temporoparietal fascia,1 diminishing or eliminating its availability for use in future soft tissue reconstruction and occasionally resulting in temporal hollowing, although, recently, techniques have been described that preserve the temporoparietal fascial and minimize these risks.2,3 A postauricular coronal incision has also previously been described in the literature, beginning 2-to-3 cm posterior to the upper attachment of the auricular helix and extending across the vertex. Although this changed the pivot point of the resultant scalp flap, the authors noted no difficulty with exposure of midface structures.4 Advantages to this technique include elimination of preauricular sensory loss, improved scar camouflage, preservation of the temporoparietal fascia, and decreased risk for facial nerve injury.4,5 The sawtooth “stealth incision” was initially described by Munro and Fearon,6 who suggested that a zigzag incision is much less visible to the eye than a straight line incision and is especially useful in very short hairstyles. They note that the scar from a straight-line coronal incision causes a separation of the hair along the line of the scar, causing it to part forward and backward away from the scar and thus increasing its visibility. The disadvantages to this modification were noted to be the increased length and time required to make and suture the incision. A template for this incision was described by Fisher et al7 in 1995 using heavy steel wire bent into a zigzag formation that can be bent to the curvature of the patient's skull and used as a template both to plan the incision and to part the hair appropriately. Although the esthetic results are superior to the straight coronal incision due to the discontinuity of the scar, the sawtooth incision still seems artificial due to its angularity. In addition, certain areas of the scar are at risk for
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1
Pavri et al
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
FIGURE 5. Follow-up photographs after 6 months show good camouflage of the surgical scar.
FIGURE 1. The posterior coronal incision is positioned just superior and posterior to the root of the helix, across the occiput, to the contralateral helical root, preserving the parietal branch of the superficial temporal artery.
FIGURE 6. Orientation of the surgical scar perpendicular to hair growth shows optimal esthetic outcomes as the hair grows out.
FIGURE 2. Dissection proceeds in the same relatively avascular subgaleal plane as the traditional coronal incision.
FIGURE 3. The final exposure allows access to the entire cranial vault from the occiput to the upper aspects of the facial skeleton.
widening, and wound healing problems may occur in the apices of the angles. The sinusoidal coronal incision described by Wilbrand et al8 provided an improved esthetic result with decreased scar visibility, with a lower risk for wound healing disturbance or scar widening. The template for the sinusoidal incision is based on the stealth incision, with each sine wave crossing the otobasion to vertex line at an angle of 60 degrees and the width of the incision approximately half of the stealth incision. However, all the incisions mentioned previously position the scar over the vertex of the skull, where it may prove to be noticeable in patients with thinning hair, male-pattern baldness, or closely cropped hairstyles. Even in patients with thick longer hair, the bitemporal incision across the vertex may be visible when the hair is wet because of changes in texture and the part. In addition, these incisions result in a temporal scar with an overall vertical vector, which is prone to visible widening.
FIGURE 4. Preoperative markings are made across the occiput below the hair whorl.
2
In addition to the esthetic considerations, in patients undergoing neurosurgery requiring the placement of extracranial implants in the frontotemporal region such as ventriculoperitoneal shunts, positioning the incision line in the occipital scalp rather than across the vertex region decreases the probability of implant exposure in the case of wound complications. The position of the incision across the occiput does predispose the patient to a very small risk for wound breakdown because of increased moisture and pressure. However, this can be minimized by placing an absorbent dressing under the head and by slightly tilting the head forward with a pillow or towel under the neck when the patient is lying on his/her back to offload pressure on the incision. This flap should not be used in patients who have had previous surgery in which the ascending branch of the superficial temporal artery may have been ligated, as well as in elderly patients in whom the anastamotic networks supplying the distal edge of the flap may not be particularly robust. For patients in whom a future midface procedure is anticipated, the upper aspects of the midface may be approached through the initial posterior coronal incision, and the lower aspects may be approached through an intraoral incision. In appropriately selected patients undergoing craniofacial surgery of the anterior or posterior vaults or the upper facial skeleton, the posterior coronal incision technique results in improved esthetic outcomes with regard to scar placement and camouflage, while adding minimal time and complexity.
REFERENCES 1. Netscher DT, Stal S, Peterson R. A critical analysis of coronal incisions. Plast Reconstr Surg 1990;86:167–169 2. Baek RM, Heo CY, Lee SW. Temporal dissection technique that prevents temporal hollowing in coronal approach. J Craniofac Surg 2009;20:748–751 3. Aojanepong C. Coronal incision with preserved temporoparietal fascia. J Craniofac Surg 2009;20:1574–1577 4. Polley JW, Cohen M. The retroauricular coronal incision. Scand J Plast Reconstr Surg Hand Surg 1992;26:79–81 5. Posnick JC, Goldstein JA, Clokie C. Advantages of the postauricular coronal incision. Ann Plast Surg 1992;29:114–116 6. Munro IR, Fearon JA. The coronal incision revisited. Plast Reconstr Surg 1994;93:185–187 7. Fisher DM, Goldman BE, Mlakar JM. Template for a zigzag coronal incision. Plast Reconstr Surg 1995;95:614–615 8. Wilbrand JF, Schaaf H, Howaldt HP, et al. Sinusoidal coronal incision. J Craniofac Surg 2011;22:2278–2280
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Posterior Coronal Incision Sabrina Nicole Pavri, MD, MBA,* Eric Arnaud, MD,† Dominique Renier, MD, PhD,† and John A. Persing, MD* Background: The coronal incision is a standard surgical approach in craniofacial surgery. It has undergone many modifications during the years in an attempt to optimize the esthetic appearance of the scar, including the sawtooth “stealth incision” and the sinusoidal incision. Methods: We describe an alternative coronal approach extending posteriorly from the postauricular region over the occiput, resulting in an axial scar. Results and Discussion: The posterior coronal incision provides equivalent exposure of the craniofacial skeleton while placing the scar in an esthetically optimal location that is much more likely to be camouflaged by hair, especially in patients with thinning hair or male-pattern baldness. It avoids a vertical temporal scar that is prone to widening and also allows the incision to be placed remotely from any neurosurgical hardware in the frontotemporal region. It may be used in craniofacial or neurosurgical procedures requiring access to the posterior or anterior cranial vaults or the upper craniofacial skeleton down to the maxillary alveolar rim. Key Words: Posterior, axial, coronal incision, craniosynostosis, craniofacial surgery (J Craniofac Surg 2015;26: 00–00)
T
he coronal incision has been a standard approach for surgical exposure of the craniofacial skeleton for many years, allowing easy access to the anterior and posterior cranial vaults and the facial skeleton above the level of the maxillary alveolar rim. Although technically camouflaged in the hair, modifications of the straight coronal incision extending across the vertex of the skull have been developed because of the esthetically unappealing widening of the scar, especially in the more visible temporal region, and its prominence when the hair is wet or extremely short.
MATERIALS AND METHODS Here, we describe a modification of the coronal incision extending from just superior and posterior to the root of the helix, across the occiput, to the contralateral helical root (Figs. 1–3). The blood supply to the scalp flap is through the posterior branches of the ascending superficial temporal artery, which anastamose with branches of the posterior auricular and occipital arteries. Care is From the *Section of Plastic Surgery, Yale University School of Medicine, New Haven, Connecticut; and †Craniofacial Unit, Department of Pediatric Neurosurgery, Hôpital Necker-Enfants Malades, Paris, France. Received July 20, 2014. Accepted for publication October 9, 2014. Address correspondence and reprint requests to John A. Persing, MD, Section of Plastic Surgery, Yale University School of Medicine, 330 Cedar Street, PO Box 208041, New Haven, CT, 06520-8041; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001374
taken not to position the incision too superiorly to preserve the parietal branch of the superficial temporal artery, because the occipital and posterior auricular artery branches are cut during the incision (Fig. 1). The dissection proceeds in the same relatively avascular subgaleal plane as the traditional coronal incision, and the additional dissection required adds minimal time to the procedure (Figs. 2, 3).
RESULTS This technique places the incision line away from the hair part and in a location less likely to be affected by the hair recession of male pattern baldness. In balding patients (Figs. 4–6), the scar in this technique is placed in the region of the occipital scalp, in an area that usually remains hair bearing even in balding patients. The scar is well camouflaged due to the orientation of the hair follicles perpendicular to the incision, and we avoid a vertical temporal scar that is prone to widening and more poorly camouflaged, as it lies parallel to the temporal hair follicles.
DISCUSSION The original bitemporal coronal incision extended in a straight line from the root of the helix over the vertex of the skull to the contralateral helical root and could be extended inferiorly as a preauricular incision depending of the exposure required. The technique usually involved preoperative shaving of either the entire head or, alternatively, a small 1- to 2-cm strip in the area of the planned incision.1 This incision transected the temporoparietal fascia,1 diminishing or eliminating its availability for use in future soft tissue reconstruction and occasionally resulting in temporal hollowing, although, recently, techniques have been described that preserve the temporoparietal fascial and minimize these risks.2,3 A postauricular coronal incision has also previously been described in the literature, beginning 2-to-3 cm posterior to the upper attachment of the auricular helix and extending across the vertex. Although this changed the pivot point of the resultant scalp flap, the authors noted no difficulty with exposure of midface structures.4 Advantages to this technique include elimination of preauricular sensory loss, improved scar camouflage, preservation of the temporoparietal fascia, and decreased risk for facial nerve injury.4,5 The sawtooth “stealth incision” was initially described by Munro and Fearon,6 who suggested that a zigzag incision is much less visible to the eye than a straight line incision and is especially useful in very short hairstyles. They note that the scar from a straight-line coronal incision causes a separation of the hair along the line of the scar, causing it to part forward and backward away from the scar and thus increasing its visibility. The disadvantages to this modification were noted to be the increased length and time required to make and suture the incision. A template for this incision was described by Fisher et al7 in 1995 using heavy steel wire bent into a zigzag formation that can be bent to the curvature of the patient's skull and used as a template both to plan the incision and to part the hair appropriately. Although the esthetic results are superior to the straight coronal incision due to the discontinuity of the scar, the sawtooth incision still seems artificial due to its angularity. In addition, certain areas of the scar are at risk for
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
1
Pavri et al
The Journal of Craniofacial Surgery • Volume 26, Number 1, January 2015
FIGURE 5. Follow-up photographs after 6 months show good camouflage of the surgical scar.
FIGURE 1. The posterior coronal incision is positioned just superior and posterior to the root of the helix, across the occiput, to the contralateral helical root, preserving the parietal branch of the superficial temporal artery.
FIGURE 6. Orientation of the surgical scar perpendicular to hair growth shows optimal esthetic outcomes as the hair grows out.
FIGURE 2. Dissection proceeds in the same relatively avascular subgaleal plane as the traditional coronal incision.
FIGURE 3. The final exposure allows access to the entire cranial vault from the occiput to the upper aspects of the facial skeleton.
widening, and wound healing problems may occur in the apices of the angles. The sinusoidal coronal incision described by Wilbrand et al8 provided an improved esthetic result with decreased scar visibility, with a lower risk for wound healing disturbance or scar widening. The template for the sinusoidal incision is based on the stealth incision, with each sine wave crossing the otobasion to vertex line at an angle of 60 degrees and the width of the incision approximately half of the stealth incision. However, all the incisions mentioned previously position the scar over the vertex of the skull, where it may prove to be noticeable in patients with thinning hair, male-pattern baldness, or closely cropped hairstyles. Even in patients with thick longer hair, the bitemporal incision across the vertex may be visible when the hair is wet because of changes in texture and the part. In addition, these incisions result in a temporal scar with an overall vertical vector, which is prone to visible widening.
FIGURE 4. Preoperative markings are made across the occiput below the hair whorl.
2
In addition to the esthetic considerations, in patients undergoing neurosurgery requiring the placement of extracranial implants in the frontotemporal region such as ventriculoperitoneal shunts, positioning the incision line in the occipital scalp rather than across the vertex region decreases the probability of implant exposure in the case of wound complications. The position of the incision across the occiput does predispose the patient to a very small risk for wound breakdown because of increased moisture and pressure. However, this can be minimized by placing an absorbent dressing under the head and by slightly tilting the head forward with a pillow or towel under the neck when the patient is lying on his/her back to offload pressure on the incision. This flap should not be used in patients who have had previous surgery in which the ascending branch of the superficial temporal artery may have been ligated, as well as in elderly patients in whom the anastamotic networks supplying the distal edge of the flap may not be particularly robust. For patients in whom a future midface procedure is anticipated, the upper aspects of the midface may be approached through the initial posterior coronal incision, and the lower aspects may be approached through an intraoral incision. In appropriately selected patients undergoing craniofacial surgery of the anterior or posterior vaults or the upper facial skeleton, the posterior coronal incision technique results in improved esthetic outcomes with regard to scar placement and camouflage, while adding minimal time and complexity.
REFERENCES 1. Netscher DT, Stal S, Peterson R. A critical analysis of coronal incisions. Plast Reconstr Surg 1990;86:167–169 2. Baek RM, Heo CY, Lee SW. Temporal dissection technique that prevents temporal hollowing in coronal approach. J Craniofac Surg 2009;20:748–751 3. Aojanepong C. Coronal incision with preserved temporoparietal fascia. J Craniofac Surg 2009;20:1574–1577 4. Polley JW, Cohen M. The retroauricular coronal incision. Scand J Plast Reconstr Surg Hand Surg 1992;26:79–81 5. Posnick JC, Goldstein JA, Clokie C. Advantages of the postauricular coronal incision. Ann Plast Surg 1992;29:114–116 6. Munro IR, Fearon JA. The coronal incision revisited. Plast Reconstr Surg 1994;93:185–187 7. Fisher DM, Goldman BE, Mlakar JM. Template for a zigzag coronal incision. Plast Reconstr Surg 1995;95:614–615 8. Wilbrand JF, Schaaf H, Howaldt HP, et al. Sinusoidal coronal incision. J Craniofac Surg 2011;22:2278–2280
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
