Youmans Neurological Surgery

1. Incision and Closure
Youmans Chapter 29

2. Outline
• Wound healing
• Indication for antibiotics
• Incision
• Surgical anatomy
• Clinical consideration
• Closure

3. Wound healing
• Inflammatory phase
• Proliferative phase
• Maturation phase

4. Inflammatory phase
Day 1-3
• Incision initiate the inflammatory phase
• Factors released from activated platelets, complement
components, and prostaglandins induce vasoconstrict 
hemostasis  vasodilatation with increase permeability
 influx of leukocyte
• PMN are the first cell to migrate into the wound followed
by macrophage and mononuclear(Day 2-3)
• Monocytes are essential for normal wound healing by
triggering invasion of fibroblasts into the wound and
initiating the proliferative or fibroblastic phase of wound
healing

5. Proliferative phase
Day 4-21
• Fibroblasts migrate into the wound at approximately day
4 after injury and deposit disorganized collagen, which
produces a scar
• Fibroplasia : restructor tissue
– lysis of fibrin platelet
– Macrophage,ECM secret growth factor induce fibroblast
– Fibroblast create collagen
• Granulation : red from vascular, macrophage, fibroblast
• Contraction : rim of wound contracture to center

6. Maturation phase
21 day – 1-2 Yrs
• ECM remodeling

7. Indication for antibiotics
• Contaminate wound : 3 hr from time to injury to
the time of ATB administration
• Traumatic wound : jet lavage or 35 ml syringe c
gauge 18 needle and debridement
• Anatomic location : head and scalp lowest, foot
highest rate of infection
• Crush injury have higher rate than linear injury
• Preoperative hair removal and its impact on
reducing surgical site infection have controversal

8. Incision
• Perpendicular to the direction of underlying musculature
contracture

9. Incision
• Perpendicular to the skin and avoid scything or
undetermining the adjacent epidermis
• Unequal bite  inversion of wound edge  inverted scar

10. Surgical anatomy

11. Scalp
• Scalp is composd of five layer
• outer three layer – skin, subcutaneous fat, galea as a unit

12. Scalp
• Scalp skin(epidermis and dermis) : 3 mm at
vertex to 8 mm at occiput
• Subcutaneous tissue : hair follicle, sweat gland,
rich vascular(dense fibrous : manual
compression more effective to control bleeding)
• Galea : aponeurotic layer that connect the
frontalis to the occipitalis muscle and is
contiguous with the temporoparietal fascia
laterally

13. Scalp
• temporoparietal fascia, epicranial aponeurosis,
superficial muscular aponeurotic system(SMAS), galeal
extension : superficial temporal a. and vein

14. Flap
• Angiosome
• Anterior aspect of face : musculocutaneous perforators
• Scalp : fasciocutaneous perforator
• Fix skin  mobile skin(superficial)  subdermal plexus  skin flap

15. Flap
• Converse scalp flap : capture two territories(superficial temporal a., supra orbital)
• McGrejor flap : capture four territories which often result in tip necrosis

16. Flap
• Randon pattern skin flap : not depend on name perforators but depend on the
random subdermal plexus
• Local small flap for small defect
• Length-to-width ratio 2:1

17. Blood supply of scalp
• Supra orbital a.(internal carotid a.  ophthalmic a.)
• Supra trochlear a. (internal carotid a.  ophthalmic a.)
• Superficial temporal a. (external carotid a.)
• Posterior auricular a. (external carotid a.)
• Occipital a. (external carotid a.)

18. Blood supply of scalp
• Anterior : supraorbital and supratrochlear a.
– Supraorbital a. exit through supraorbital
notch,superficial to orbital rim 1.5 cm and lateral to
midline 3 cm
– supratrochlear a.,1 cm superior to medial palpebral
ligament, 1.5 cm lateral to midline
• Posterior territory : medial and two lateral occipital
a.,5 cm lateral to occipital protuberance

19. Blood supply of scalp
• Posterolateral territory : posterior auricular a.,2 cm
inferior to the auditory canal
• Lateral scalp territory : frontal and parietal branch of
the superficial temporal a.(superficial temporal a.
give branch to middle temporal a.the blood supply to
the temporalris muscle and deep temporal fascia)

20. Facial nerve
• Facial n. lies within a small fat pad between the layers of
the deep temporal fascia,posterior to the superficial
temporal a. and vein,at level of zygomatic arche
• 2.5 cm anterior to the tragus
• 1.5 cm lateral to the orbital rim
• Lie within deep temporalis fascia
• Should be preserve when elevating a pericarnial flap

21. Clinical consideration

22. Frontosphenotemporal or
pterional craniotomy
• anterior aneurysms and parasellar, sphenoid and
anterior skull base tumour
• Incision from the roof of zygoma to the linea
temporalis and anteriorly to the center of forhead
• Five aesthetic part unit : two temporal, two brow and
one central component

23. Frontosphenotemporal or
pterional craniotomy
• Coronal incision,providing better exposure and
cosmetic result because it preservs all the aesthetic
units of the head.
• Longer incision, necessitate operative time
• Should be preserve frontal branch of the facial nerve
• Detach of the muscle from it superior insertion result
in retracton of m. inferiorly and muscle wasting
• Leaving a cuff of temporalis m. superiorly attached
to skull to provide, reapproximating m. fiber and
resultant in muscle wasting

24. Subtemporal craniotomy
• Hoarseshoe-shape flap
• Tentorial, clivus and basilar a lesion
• Becareful, superficial temporal a. and posterior
auricle a.

25. Midline suboccipital craniotomy
• Inconspicious scar, advantage of vascular between
two bellies
• Reliable closure is complicated by many factor
– Radiation
– Embolization
– Previous scalp surgery
– > 60 Years

26. Closure
• Primary closure : simple, atraumatic,
noncontaminated wound
• Goal
– Obliterate dead space
– Distribute tension along deep suture line
– Maintain suture strength until tissue tension strength
adequate
• Interrupted stitch,it avoid compromising the vessel
within the galea suppling the scalp but longer
operative time
• Metallic staples may used in region of compromised
vascularity to improve potential

27. Closure
Monofilament Multifilament
Infection less more
Tension Less tension More tension
Galea,scalp
Nylon