Incisions and closures

Wound healing

• Closed incisional wounds regain about 20% of the original skin tensile strength after 3 weeks and up to 70% at 6 weeks with maximal tensile strength of 80% of the original strength regained after a year

• The protective, moisturizing epidermal layer is restored within 48 hours of closing a wound

Incisions

• The incision should be perpendicular to the skin

• Elliptical excisions placed along Langer’s lines achieve the greatest width of tissue removal and heal with minimal tension and scarring

Surgical anatomy

• The scalp extends from the superior orbital margin to the superior nuchal line and is composed of five layers:– Skin– subCutaneous tissue – site of blood vessels– galeA– Loose connective tissue– Pericranium

Scalp blood supply

AnteriorSupraorbital

Supratrochlear

Lateral Superficial temporal

Posterior Occipital

Posterolateral Posterior auricular

Special considerations

• Facial nerve – lies deep to the superficial temporal fascia, courses 2.5 cm anterior to the tragus and 1.5 cm lateral to the orbital rim

• STA – contributes to the blood supply of the periosteum and skull in the frontoparietal areas

Closure

• Youmans supports monofilament closure

Craniotomies

Pre-op management

• Risks– Overall risk of post-op hemorrhage: 0.9-1.1%– Anesthesia complications: 0.2%– Wound infection: 2%

Pre-op management

• Preop orders– Steroids for tumor patients: give 50% higher dose

6 hours prior to OR. If not on steroids, give dexamethasone 10mg 6 hours PTOR

– Antiepileptics: continue same dose if already on AEDs. If expecting a cortical incision, give levetiracetam 500mg PO

– Antibiotics

Suboccipital craniectomy

• Positions:– Sitting– Lateral Oblique (park bench)– Concorde position – prone with thorax elevated,

neck flexed and tilted away from the side on which the surgeon will be standing

Suboccipital craniectomy

• Linear paramedian incisions– Microvascular

decompression for trigemnial neuralgia

– Small vestibular schwannomas

Suboccipital craniectomy

• Hockey-stick incision– C2 to just above the

inion– Laterally to just beyond

the mastoid tip

Suboccipital craniectomy

• Midline suboccipital incision– 6cms above the intion to the C2 spinous process

Suboccipital craniectomy

• Limits:– Transverse sinus superiorly– Sigmoid sinus laterally– Take care of vertebral arteries on inferior limits

Pterional craniotomy

• Indications– All aneurysms of the anterior circulation– Basilar tip aneurysms– Suprasellar tumors

• Position– Supine, ipsilateral shoulder elevated

Pterional craniotomy

• Skin incision

Pterional craniotomy

• A – posterior insertion of zygomatic arch

• Z – intersection of zygomatic bone, superior tempora line, supraorbital ridge

Temporal craniotomy

• Indications– Temporal lobe biopsy– Temporal lobectomy– Hematomas– Tumors

• Position– Supine, head turned with shoulder roll

Temporal craniotomy

• Burrholes:– Posterior insertion of

zygomatic arch– Anterior zygomatic arch

• Temporal lobectomy:– Safe to resect up to 4-

5cms in dominant lobe (avoid Wernicke’s), 6-7 cms in nondominant lobe (avoid optic radiations)

Frontal craniotomy

• Incision: 1cm anterior to tragus carried superiorly and a little posteriorly before being brought to midline

• Burrholes:– Junction of anterior

temporal line and orbital rim

– Posterior to the depression of the sphenoid wing

– Just behind the hairline

Decompressive hemicraniectomy

• Indications:– Malignant MCA/ICA infarcts– Traumatic intracerebral hematomas

Decompressive hemicraniectomy