Step 1 Locating the Incision Line and Preparation

Two factors are considered when designing the line of incision. The first is the hairline of the patient. In males, expected recession at the widow's peak as well as male pattern baldness should be contemplated. The incision for balding males might be placed along a line extending from one preauricular area to the other, several centimeters behind the hairline (Fig. 6-7), or even more posteriorly. Incision made farther posteriorly need not reduce access to the operative field, because

the amount of skeletal exposure depends on the inferior extent of the incision, not on the anteroposterior position. In most females and nonbalding males, the incision may be curved anteriorly at the vertex, paralleling but remaining 4 to 5 cm within the hairline (Fig. 6-8). In children, the incision is preferably placed well behind the hairline to allow for migration of the scar with growth. If a hemicoronal incision is planned, the incision curves forward at the midline, ending just posterior to the hairline. Curving the hemicoronal incision anteriorly provides the relaxation necessary for retraction of the flap.

Hemicoronal Incision
Figure 6- 8 Incision placement for most female patients and males with no signs or family history of baldness. The incision is kept approximately 4 cm behind the hairline.

The second factor considered in designing the location of the incision is the amount of inferior access required for the procedure. When exposure of the zygomatic arch is unnecessary, extension of the coronal incision inferiorly to the level of the helix may be all that is necessary. The coronal incision can extended inferiorly, however, to the level of the lobe of the ear as a preauricular incision. This maneuver allows exposure of the zygomatic arch, temporomandibular joint (TMJ), and/or infraorbital rims.

Extensive shaving of the head before incision is not medically necessary. In fact, direction of the hair shafts may be used as a guide for incision bevel to minimize damage to the follicles. The presence of hair makes closure more difficult, but does not seem to cause an increase in the rate of infection. A comb can be used to separate the hair along the proposed incision line. Long hair can be held in clumps with elastics placed either before or after sterile preparation. This measure minimizes the annoyance of loose hair in the operative field (Fig. 6-9). If shaving the hair is desired, it need not to be extensive - a small strip, approximately 12 to 15 ,,. Is adequate. The drapes can be sutured or stapled to the scalp approximately 1,5 cm posterior to the planned incision site, covering the posterior scalp and confining this hair.

Figure 6- 9 Technique of gathering hair into clumps and securing the clumps with small elastics bands. Small bundles of the hair are twisted with the fingers and each is grasped in the middle with a hemostat loaded with an elastic band. The elastic band is rolled off the hemostat onto the hair bundle below the tips of the hemostat, which can be removed.

Figure 6- 9 Technique of gathering hair into clumps and securing the clumps with small elastics bands. Small bundles of the hair are twisted with the fingers and each is grasped in the middle with a hemostat loaded with an elastic band. The elastic band is rolled off the hemostat onto the hair bundle below the tips of the hemostat, which can be removed.

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