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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Neurosurg Clin N Am 13 (2002) 405410

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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[1] Seitchik MW, Kahn S. The eects of delay on

circulatory eciency of pedicled tissue. Plast

Reconstr Surg 1964;33:16.

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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;

147:81821.

[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

1996;23:68393.

[19] Burgess EA, Mayer MH, Hollinger J. Bone grafting

andsubstitutes.In:AchauerB,EriksonE,GuyuronB,

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and outcomes. St. Louis: Mosby; 2000. p. 65771.

[20] Hollinger JO, Brekke J, Gruskin E, et al. The role of

bone substitutes. Clin Orthop 1996;324:5565.

[21] White DN. CT scans, multidimensional refor-

matting, CAD/CAM produced models in the diag-

nosis and treatment of craniofacial deformity. In:

Osterhout DK, editor. Aesthetic applications of

craniofacial techniques. Boston: Little Brown &

Company; 1991. p. 95107.

[22] Barone CM, Jimenez DF. Endoscopic craniec-

tomy for early correction of craniosynostosis. Plast

Reconstr Surg 1999;104:196573.

[23] Koh KS, Park S. Endoscopic harvest of sural nerve

graft with balloon dissection. Plast Reconstr Surg

1998;101:8102.

[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-

illofacial surgeon. J CranioFac Surg 1997;8:926.

[26] Rubin PJ, Yaremchuk MJ. Complications and

toxicities of implantable biomaterials used in facial

reconstructive and aesthetic surgery. A comprehen-

sive review of the literature. Plast Reconstr Surg

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[27] Ilizarov GA. The tension stress eect on the genesis

and growth of tissues. Part 1: the inuence of

stability of xation and soft tissue preservation.

Clin Orthop 1989;238:24981.

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expansion in experimental craniosynostosis. Plast

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base expansion: craniofacial eects. Plast Reconstr

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[31] McCarthy JG, editor. Distraction of the cranio-

facial skeleton1999New York: Springer-Verlag.

[32] Robson MC, Hill DP, Smith PD, et al. Sequential

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mechanistic response. Ann Surg 2000;231:60011.

[33] Kallianinen LK, Hirshberg J, Marchant B, Rees RS.

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to surgery in themanagement of pressure ulcers. Plast

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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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[4] Munro IR, Fearon JA. The coronal incision

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[5] Fisher DM, Goldman BE, Mlakar JM. Template

for a zigzag coronal incision. Plast Reconstr Surg

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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-

dissection cautery needle versus the cold scalpel in

bicoronal incisions. J Craniofac Surg 1998;9:3447.

[8] Burm JS, Oh SJ. Prevention and treatment of wide

scar and alopecia in the scalp: wedge excision and

double relaxation suture. Plast Reconstr Surg 1999;

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[9] Siddique MS, Matai V, Sutclie JC. The preoper-

ative skin shave in neurosurgery: is it justied? Br J

Neurosurg 1998;12:1315.

[10] Nair S,GiannakopoulosG,GranickM, SolomonM,

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ated scalp in patients with recurrent glioma. Neuro-

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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