This document discusses incision and closure techniques for surgery involving the scalp. It covers wound healing phases, antibiotic indications, scalp anatomy including blood vessels, and closure considerations. The scalp has 5 layers (skin, fat, galea, fascia, muscle) supplied by temporal, occipital and frontal arteries. Common craniotomies like frontotemporal involve coronal incisions along aesthetic units. Subtemporal and suboccipital approaches also discussed. Primary closure aims to eliminate dead space and distribute tension until tissue strength recovered.

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